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HAND-BOOK 



SURGERY. 



HAND-BOOK 

OP 

S U R G E E Y: 

Wiil) /ifti] SUustrfltinns. 



BEING A PORTION OP 



AN ANALYTICAL COMPENDIUM 



VARIOUS BEANCHES OP MEDICINE. 

/ BY 

J H N "4^ E I L L, M. D., 

SURGEON TO WILLS' HOSPITAL, DEMONSTRATOE- OF ANATOMY IN THE UNIVERSITY OF 

PENNSYLrANIA, LECTURER ON ANATOMY IN THE PHILADELPHIA MEDICAL 

INSTITUTE, FELLOW OF THE COLLEGE OF PHYSICIANS, ETC. 



FRANCIS GURNEY, SMITH, M. D., 

LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, 

PHYSICIAN TO THE ST. JOSEPH'S HOSPITAL, FELLOW OF THE 

COLLEGE OF PHYSICIANS, ETC. 

SECOND EDITION, REVISED AND I M PROVED. 

PHILADELPHIA: L \' " 

B L A N C H A R D AND LEA. ■^"•■• 



. isr>2. 



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0. SHERMAN, TR INTER. 



CONTENTS. 



PAGE 

Inflammation, - - -.- - - - -13 

Results of inflammation, ----- 16 

Treatment of inflammation, - - - - - 18 

Abscess, -------- 20 

Ulcers, - - - - - - - - - 22 

Erysipelas, --------24 

Furunculus, - - - - - - - -25 

Anthrax, - - - - -- - - 25 

Chilblains, - -- - _ _ - -26 

Frostbite, -------- 26 

Burns and scalds, - - - - - - - 26 

Wounds, - - - - -- - - 27 

incised, - - - - -r - - -27 

contused and lacerated, - - - - - 28 

punctured and penetrating, - - - - - 29 

poisoned, -------29 

Hydrophobia, - - - - - - - -30 

Gunshot wounds, -------31 

Tetanus, - - - - - - - -33 

Caries,- ------.-34 

Necrosis, - - - - - - - -35 

Exostosis, --------35 

Fragilitas ossium, - - - - - - - 35 

Mollities ossium, -------35 

Rickets, - - - - - - - -36 

Spina ventosa, - - - - - - - 36 

Osteo-sarcoma, - - - - - - - • - ;^)(5 

Coxalgia, - - - - - - - - 37 

Fractures, - - - - - - - -37 

of the nose, ------- 39 



VI CONTENTS. 

PAGE 

Fractures of the upper and lower jaw, - - - - 39 

of the spine, -------40 

of the pelvis, - - - - - - -40 

of the ribs, -------40 

of the sternum, - - - - ^ - - - 41 

of the scapula, _ _ - _ - _ 41 

of the clavicle, - - - - - - -42 

of the humerus, _-_-_- 43 

of the radius and ulna, - - - - - - 44 

of the carpus and phalanges, ----- 46 

of the femur, - - - - - - -46 

of the patella, -------49 

of the tibia and fibula, - - - - . - - 49 

of the tarsus, &c., - - - - - — 50 

Compound fracture, - -- - - - -61 

Dislocations, - - - - -- - 51 

of the jaw, - - - - - - -52 

of the spine, -------53 

of the ribs, - - - - - - -53 

of the clavicle, - - - - - - 54 

of the humerus, -^- - - - - -54 

at the elbow, -------56 

at the wrist, - - - - - - -57 

of the femur, -------58 

of the knee, - -- - - - -61 

of the patella, ------ 61 

of the ankle, - - - - - - -62 

of the foot, ------- 62 

Injuries of the head, - - - - - - - 62 

Concussion, -------63 

Fractures of the cranium, - - - - - - 64 

Compression, - -- - - -- 65 

Trephining, - - - - - - --66 

Injuries and diseases of the face, nose, and mouth, - - 67 

Wounds and affections of the throat, - - - - - 69 

Injuries and surgical affections of the chest, - - - 73 

Wounds of the abdomen, - - - - - - 74 

Artificial anus, ----_-- 75 

Hernia, - - - - - - - -76 

Inguinal hernia, ------ 78 

Femoral hernia, - - - - - - -81 

Umbilical and other varieties of hernia, - . - - 82 

Fistula in ano, -- -- - - - -83 



CONTENTS. • Vll 

PAGE 

Fissure of the anus, ------ 85 

Hemorrhoids, - - - - - - -" - 85 

Prolapsus ani, ------- 86 

Encysted rectum, -------86 

Imperforate anus, - - - - - - 87 

Urinary calculus, -------87 

Lithotomy, ------- 89 

Lithotrity, ---.---- 92 

Lithotripsy, --.-_-- 92 

Venereal disease, - - - - - - - 93 

Gonorrhoea, _----_. 93 

Syphilis, _.--.-_- 95 

Stricture of the urethra, ------ 97 

Fistula in perineo, - - -'- - - -99 

Enlarged prostate, ------ 99 

Inflammation of the bladder, - - - - - - 99 

Orchitis, - - - - - - - - 100 

Hydrocele, - - - - - - - - 100 

Circocele, -------- 101 

Aneurism, -------- lOl 

of the aorta, - - - - - - 103 

of the carotid, ------- 104 

Axillary aneurism, - - - - - --,104 

Brachial aneurism, ------ 105 

Inguinal aneurism, - - -- - - 106 

Popliteal aneurism, - - - - - -107 

Varicose aneurism, - - - - - - 108 

Amputation, - - -- - - - -109 

of the thigh, - - - - - - - 110 

of the hip joint, - - - - - - - 111 

of the leg, - - - - - - - 112 

of the foot, ------- 113 

of the great toe, - - - - - - 114 

of the shoulder joint, - - - - - -114 

of the arm, - - - - - - - 115 

of the forearm, - - - - - - -116 

at the wrist, - - - - - - - 116 

of the fingers, - - - - - - -116 

Cancer, - - - - - - - - 117 

Encephaloid, - - - - - - --117 

Scirrhus, - - - - - - - - IIS 

Colloid, - - - - - - - - 119 

Club Foot, - - - - - - - 119 



Vlll • CONTENTS. 

PAGE 

Diseases of the eyelids, ------ 12I 

Hordeolum, -.--._- 121 
Ophthalmia tarsi, - - - - - - -121 

Entropion, ------- 122 

Ectropion, -------- 122 

Ptosis, - - - - - - - - 122 

Diseases of the lachrymal apparatus, - - - _ 122 

Obstruction of the lachrymal duct, - - - - 123 

Fistula lachrymalis, - - - - - - - 123 

Conjunctivitis, ------- 124 

Ulcer of the cornea, - - - - - - - 125 

Sclerotitis, •• - - - - - - 125 

Iritis, - - - - - - - - - 125 

Cataract, - - - - - - . - 126 

Amaurosis, - --- - - - - 127 

Strabismus, - - - - - - - 127 

Glossary of diseases of the eye, - - - - - 129 



SURGERY. 



INFLAMMATION. 

The definitions of inflammation vary with different authors. 
That of Miller is as satisfactory as any other. He defines inflam- 
mation to be '' a perverted condition of the blood and blood-vessels 
of a part interrupting its healthful function, and changing its normal 
structure ; ordinarily attended with redness, pain, heat, and swelling ; 
and inducing more or less disturbance of the general system. '^ The 
term should be limited to processes essentially morbid. 

The transition from health to inflammation may be divided into 
three stages: 1. Simple vascular excitement; 2. Active congestion; 
3. True inflammation. 

1. Simple Vascular Excitem^ent. — When any irritant is applied 
to the skin, an impression is produced through the nervous system 
which is manifested particularly in the blood-vessels. 

At first the blood circulates with great rapidity, although the 
small arteries and capillaries are of diminished calibre. Afterwards 
the vessels yield and are dilated, and an increased quantity of blood 
circulated with great rapidity, with a tendency to serous and plastic 
exudation. The function of the part is exalted, and this may be 
manifested by excessive nutrition or secretion. This is simple vas- 
cular excitement. 

2. Active Congestion. — More blood is sent to the part, and the 
capillaries and minute arteries begin to give way under the increased 
pulsation of larger arterial trunks ; by over-distension, the vascular 
coats lose their tonicity. " And partly from this cause, partly on 
account of change in the blood itself, which seems more viscid, with 
its corpuscles less distinct, and, when examined by the microscope, 
is found especially to possess an increased number of colourless 
' lymph globules,^ unusually adhesive to each other, and to the walls 
of the vessel, and so manifestly operating obstructively — and partly, 
also, it is probable, from an increase of vital attraction between the 
blood and surrounding parenchyma — the circulation loses its acquired 
rapidity, and becomes slower even than in health. The red corpus- 



14 SURGERY. 

cles are no longer limited to the central current^ but are encroaching 
more and more on the lateral and clear ' lymph spaces/ Exuda- 
tion is more copious than in the previous stage ; it consists of serum 
and of liquor sanguinis^ the latter usually predominating : and when 
the action has been for some time sustained^ and as it were, esta- 
blished in the part, fibrin alone may be deposited/^ '' The natural 
function of the part is not simply exalted, but begins to be perverted, 
for example, secretion is not only increased, but changed in its cha- 
racter/^ Nutrition is becoming more and more disturbed, — this is 
the commencement of diseased action. " This action may resolve 
after the removal of its simple exciting cause ] or it may be sus- 
tained for some time, as in the healing of wounds, and the closing 
of ulcers ; or it may advance to 

^^3. True Inflammation. — The change which, in the preceding 
stage, had begun in the blood, is now completed. The over-disten- 
sion of the capillaries is established ; the capillary power is for a 
time gone, perhaps in consequence of diminution or actual suspen- 
sion of the nervous influence ; and the coats of the capillaries and 
other vessels are thickened, softened, and impaired in cohesion, being 
themselves the subjects of structural change. The languor of cir- 
culation approaches stagnation, and at some points this has actually 
occurred ; every part of the distended capillaries is occupied by 
crowded coloured and colourless corpuscles; partly, it may be, 
from increased attraction between the former and the surrounding 
parenchyma, partly by accumulation and adhesion of the latter to 
each other and to the capillary walls. The altered liquor sanguinis 
is exuded in profusion. The capillaries also give way in their 
. coats, and from the lesion, blood is extravasated in mass. Suppura- 
tion is in progress by extravascular degeneration of the fibrinous 
effusion, or else by a secretive elaboration of it ere yet it has left 
the vessel. Brealdng up and disintegration of texture ensue, ac- 
cording to the extent of extravasation and suppuration ; and the 
disintegrated texture is commingled with the effusion. The forma- 
tive power has ceased, and the opposite condition, a tendency to 
disintegration, from diminution of vitality, has become established. 
Disorder of function is complete; secretion, for example, being in 
the first place arrested, and when restored, more vitiated than 
before.^^ 

The local symptoms are redness, swelling, heat, pain, throbbing, 
increased sensibility, disorder of function, arrest and change of se- 
cretion. 

Redness. — -This is due to an afflux of blood to the part; the ves- 
sels become distended, and the capillaries convey red blood; the 
proportion of the red globules is also increased by the exudation of 
the serum. The degree varies in different tissues, and according to 
the intensity of the action; compare^ for instance, an inflamed tendon 



INFLAMMATION. 1 

with an inflamed mucous membrane. The tint varies also between 
a bright scarlet and a deep purple. Perw/j/nenry is characteristic 
of inflammatory redness. The redness of blushing is not indicative 
of inflammation^ because it is momentary^ and not conjoined with 
other symptoms. 

Sioelling. — This is occasioned by the increased quantity of bloody 
and an effusion of serum^ puS; &c. The swelling of inflammation 
must be conjoined with other symptoms also, for in oedema there is 
swelling, but not inflammation. It must be gradual in its develop- 
ment : the sudden swelling produced by a hernia or dislocation is 
not that of inflammation. It must also be recent, not like the te- 
dious growth of a genuine tumour. Swelling may be injurious, as 
in the brain or orbit of the eye ; or it may be useful, as in a frac- 
ture, &c. It is most remarkable in loose textures; also in the breast, 
testicles, and lymphatic glands. 

Heat, — This depends upon a more rapid oxidation of the tissues, 
which are also supplied with an increased quantity of blood. Heat 
of inflammation may be partly actual, as ascertained by the touch or 
the thermometer, and partly the result of a perverted nervous func- 
tion, estimated only by the patient. It must be permanent, and 
conjoined with other symptoms to be characteristic, for in hectic 
there is burning of the hands and feet, yet no inflammation is 
there. 

Pain, — Is caused partly by the pressure upon the nerves of the 
inflamed spot, and the distension of the arteries which are supplied 
by small nerves ; and partly by disordered function. Mechanical 
pressure increases it, for instance, by the hand in peritonitis, or in- 
spiration in pleurisy. Pain varies with the natural sensibility of 
the part affected, hence inflammation of the skin is more painful 
than that of cellular tissue. It is proportionate to the yielding 
nature of the structure affected; thus inflammation produces more 
pain in bones and ligaments, than in mucous membrane. 

Pain is not always indicative of inflammation — for example, in 
spasm and neuralgia. In spasm the pain comes on suddenly, and 
is relieved by pressure; in neuralgia it is intermittent. Not so with 
inflammation — in the latter the pain gradually increases from the 
first; if it suddenly disappears suspicion is excited lest gangrene 
has supervened. Pain may be sympathetic, and referred to a part 
at a distance : in coxalgia, the pain is at the knee ; in liver disease, 
in the shoulder ; in disease of the kidney, at the orifice of the ure- 
thra. This is a point of practical importance in the application oi 
remedies. 

Increased sensihilffj/. — This may be illustrated b}' intolerance of 
light when the eye is inflamed ; the tenderness of the skin in erysi- 
pelas; the rejection of food by the stomach, and the constant urina- 
tion if the bladder is the seat of inflammation. 



16 SURGERY. 

Disorder of function. — The stomach cannot digest^ nor the kidney 
secrete. If the brain or spinal cord be the seat; we may expect con- 
vulsionS; or paralysis. 

The causes of inflammation may be divided into predisposing and 
exciting. 

Predisposing causes. — Include sanguine temperament, excitabi- 
lity; plethora, excess in food, drink, or exercise; debility, mias- 
mata, bad air, food, and clothing; previous disease, &c. These may 
be considered as constitutional or idiopathic. 

Exciting causes. — May be direct, such as the chemical effects of 
acids, salts, &c. ; or mechanical effects of wounds, pressure, &c. In- 
direct, or vital, such as heat and cold, cantharides and turpentine. 
Specific, as in the instance of vaccine virus. 

The duration and character of inflammation are modified by the 
nature, situation, and condition of the part affected, and the tempe- 
rament and diathesis of the patient. Age, sex, habit, atmosphere, 
and season, all exercise an important influence in its progress and 
type. 

RESULTS OF INFLAMMATION. 

1. Resolution. — This is the most favourable result. It is the re- 
storation of the part, as regards both structure and function, to its 
original and normal state. Effusion takes place, the vessels are 
relieved, the red globules move on, absorption takes place, and the 
usual symptoms subside. Delitescence is the sudden disappearance 
of inflammation ; and when it is attended by the establishment of a 
new one, the term tnetastasis is used. 

2. Excessive deposit. — Either of serum or fibrin, which has ex- 
uded through the coats of the vessels. When serum is effused into 
cellular tissue it constitutes cecZema, which is characterized by J9i7^m(/ 
on pressure ; when effused and collected in serous membranes, it 
constitutes dropsy. The effusion of fibrin requires a higher degree 
of inflammation, upon the subsidence of which new structures are 
formed by the organization of the fibrin, and parts are repaired ; 
hence the term plastic is applied to it. Thus, wounds unite, bones 
knit, and arteries consolidate. 

8. HemorrJiage. — Occasioned by the destruction of the coats of 
the vessels. If it occur in the interior, it is termed extravasation. 
It is usually injurious, by producing pressure and exciting irrita- 
tion, as, for instance, in the humours of the eye, or membranes of 
the brain. 

4. Suppuration. — The formation of a fluid called pus. It is 
called laudable when it is yellow, creamy, and opaque ; insoluble in 
water, but readily mixing with it. It has no odour, but a slightly 
sweetish taste. It is not corrosive, but bland and protective to 
tender granulations until covered by cuticle. When confined, it 



RESULTS OF INFLAMMATION. 17 

produces disintegration of the textures in contact, by pressure. It 
is the result of a vital action. It consists of a fluid and globules. 
The fluid is the liquor sanguinis of blood eff'used ; this separates into 
serum and fibrin; the fibrin becomes granular by the formation of 
exudation corpuscles, and these degenerate into pus-globules. When 
pus is thin and acrid it is termed iA:lior, consisting mostly of serum. 
In scrofulous persons it is flaky. When it contains blood it is called 
sanies. When it is of a leaden colour, thick, coagulated, and very 
ofiensive, it is sordes. Sometimes it is mixed with a subtle virus, as 
the venereal or vaccine ; it is then said to be specific. When mixed 
in the mucous or serous discharges, it is termed sero-purulent or 
muco-purulent. 

When suppuration is profuse and long continued, in a debilitated 
frame, it produces a fever called hectic, which is a constitutional 
irritation diff'erent from the inflammatory type. It is remittent, and 
attended with paleness of surface, except upon the cheeks. The 
appetite is good, but yet there is great emaciation. The tongue is 
clean, at first moist, but afterwards dry and glazed or aphthous. 
The bowels are constipated, or else attended with a diarrhoea, termed 
colliquative. The palms and soles burn, and there is great thirst. 
Respiration is rapid and short. The pulse is frequent and small. 
At noon there is increased fever preceded by a chill ; at night there 
is perspiration, most profuse towards morning. The eyes are bright, 
though sunk in hollow orbits ] and though there may be sleepless- 
ness, lassitude, and debility, yet the mind is clear and the spirits are 
good. 

6. Ulceration. — Hunter supposed that it was entirely the result 
of absorption. It is more properly a vital softening of a texture 
changed by inflammation and suppuration ; becoming disintegrated 
and fluid, it passes away with the pus. The more violent the inflam- 
mation, the more rapid is the destruction ; the term phagedenic is 
applied to those ulcerations in which the part is apparently eaten or 
consumed with unusual rapidity. Congestion is a predisposing 
cause of ulceration. The skin, mucous membranes, and cellular 
tissue, yield more rapidly in ulceration than the vascular, nervous, 
and fibrous tissues. Those of intemperate habits, and of scrofulous 
or syphilitic taint, are most liable to its ravages. The parts most 
likely to be afi'ected are those whose circulation is weak and languid, 
such as the lower extremities, and parts newly formed, such as cica- 
trices, callus, and tumours. 

6. Mortification. — This term includes the dying and death of a 
part from injury or disease. Gangrene denotes the process of 
dying, and is recognised by the following signs. Eedness is changed 
into a livid hue ; circulation is arrested, so is cftusion, and there is 
less tension. Pain and heat abate, often suddenly, rutrosconco 
commences, and there is an ofl'ensive smell. Phlyeteniv, or vesicles 



18 SURGERY. 

filled with putrid serum^ appear over the skin. Sj>liacelus is the 
completion of the gangrene. The part is cold and insensible ] 
shrunken, soft, and flaccid; crepitates distinctly, o\Ying to its con- 
taining gas, the result of putresence ; vital action has ceased, and 
the colour becomes black if the parts are exposed to the air. A 
slough is a small sphacelation. Nature makes an effort to throw off 
an injurious mass. The living part in contact with the dead in- 
flames ; and, in consequence, the abrupt livid line is bordered by a 
diffuse, red, and painful swelling — the line of demarcation ; this 
vesicates, the vesicle bursts, puriform matter is discharged, and an 
inflamed and ulcerating surface is disclosed — the line of separation. 
The furrow deepens ; skin and cellular tissue yielding first, the ten- 
dons and arteries resisting for some time. No hemorrhage occurs 
during gradual division of the parts ] the arteries are sealed by the 
effusion of fibrin during the inflammation. But when the mortifica- 
tion is rapid, as in acute hospital gangrene, arteries are found playing 
in the dark and putrid mass alive, whilst all is dead around them. 
At length they yield, and death is hurried on by haemorrhage. 

The constitutional symptoms are of a typhoid form. The pulse is 
frequent and small, irregular or intermittent. The countenance is 
anxious, the face livid, the nose pinched, and the lips contracted. 

Anxiety is soon changed into stupidity of expression, as if the 
patient were under the influence of opium or alcohol; sighing, hic- 
cup, and involuntary movements of the hands and fingers are now 
observed, such as picking and fumbling with the bedclothes. Appe- 
tite fails ; the tongue is coated with a brown fur, except at the tip 
and edges. The lips and mouth are dry and incrusted ; swallowing 
is difficult. The mind is stupid, wavering, and subject to illusions; 
the articulation is thick and broken. Still more marked are the 
deathlike coldness, the clammy sweat, the small, indistinct, and 
flickering pulse, and the cadaverous expression. In this state a 
patient will sometimes lie for hours, and die without a struggle. 

Mortification may be acute or chronic. The acute comprehends 
the humid, inflammatory, and traumatic. The chronic — the dry 
and idiopathic. 

The caiLse of mortification is a want of vital power, and may be 
the result of high inflammation, mechanical injury, pressure, heat, 
obstruction to the return of venous blood, deprivation of nervous 
agency, interruption to arterial supply, as by aneurism or tourniquet, 
cold, general debility, bed-sores, improper food, spurred rye. 

TREATMENT OF INFLAMMATION. 

The first object is always to remove the cause, and afterwards to 
prevent or diminish the inflammatory action. The chief means are 
termed antiphlogistic, and consist of 

General Bloodletting. — This is only required when the inflamma- 



TREATMENT OF INFLAxMMATION. 19 

tion is severe, as in erysipelas and compound fractures, when im- 
portant organs are involved, such as the lungs, bladder, kidney, eye, 
and peritoneum. If resorted to unnecessarily, it produces conges- 
tions, effusions, and atrophy. Syncope, or fainting, is produced 
when bleeding is pursued to a great extent. It is occasioned by the 
removal of the natural stimulus of the heart — the blood, and by the 
sedative influence transmitted from the brain, when deprived of its 
share of arterial blood. The benefit to be derived from bleeding is 
not merely the loss of superabundant blood, but also the sedative 
influence, whereby the emptied capillaries can resume their natural 
tone. A rapid full stream from a large orifice will soon produce 
syncope, if the patient be sitting or standing; whereas the system 
may be almost drained of blood by a slow stream from a small aper- 
ture, before faintness ensues, if the recumbent position is main- 
tained. Bleeding is not to be regulated by its amount, but by its 
effects. As a general rule, the blood should flow until there is 
some paleness of the lips, sighing, nausea, fluttering of the pulse, or 
relief of pain. The ability to bear bleeding will vary according to 
age, sex, temperament, and disease. A man in health will faint 
usually from the loss of fifteen ounces; the same person, with a 
severe inflammation, particularly of the head, will bear double that 
amount. Reaction takes place after bleeding, the pulse rises, and 
pain increases, often to such an extent, as to require a second amount 
to be taken. A smaller quantity will now produce the same effects 
as a large one in the first instance. The operation is usually per- 
formed at the bend of the arm, in the neck, or in the anterior tem- 
poral artery. 

Local Bleeding. — This is preferable when the inflammatory action 
is not high; when the powers of the system are low, when the in- 
flammatory action on the part has been fully established, and there 
would be no benefit from a general bleeding, and when extreme age 
forbids it. 

Cupping. — By this means blood is obtained more rapidly than 
by leeches, and we have the advantage of general bleeding com- 
bined with local abstraction. 

Leeching. — Leeches can be applied where cups cannot. In order 
to apply them, the part should be first washed, and if they will not 
stick, a little cream or blood should be smeared on it. Their appe- 
tite is increased by being dry. If slow to bite, immersion in warm 
porter will be useful. Their bites are sometimes troublesome from 
haemorrhage. This is arrested by the mur. tinct. ferri, or a fine 
point of nitrate of silver. American leeches will draw a 5 or 5!^^ 
of blood; foreign leeches take an 3 or giss. Salt will occasion thorn 
to drop off. 

Purgatives. — They deplete, by causing an increase of mucous 
exhalation from the bowels. They also act as derivant, prevent 
assimilation of nutrition, and promote absorption; they are particu- 



20 SURGERY. 

larly useful in diseases of the head, but are contra-indicated in bad 
fractures, and inflammatory affections of the bowels. 

EmeticSy diaphoretics, and diuretics are useful at the outset, 
emptying the stomach, and promoting perspiration, particularly 
the tart. ant. et potassae. 

Mercury. — Not only^as a purge, but gradually introduced into the 
system, it seems to exert a tonic effect on both the extreme blood- 
vessels and the lymphatics; that is, in the absorbents, thus prevent- 
ing or limiting impending effusion, and at the same time expediting 
the removal of that which had already been exuded. 

Ojpium. — Particularly useful when combined with calomel, and 
given after bleeding. Before bleeding it arrests secretion, and stimu- 
lates, — afterwards it soothes the nervous system, relieves pain, and 
prevents reaction. 

A strict diet must be maintained, and the drink should be refri- 
gerant ; at the same time both body and mind should be at rest, and 
there should be a good supply of fresh air. 

Local Remedies. — Complete rest of the inflamed part. Elevated 
position, so as to favour the return of blood. Cold applications, 
ice-water, solution of sugar of lead, and muriate of ammonia — 
especially in the early stages ; for in high inflammations warmth 
and moisture are very grateful to some persons — relaxing tension, 
and assuaging pain. Nitrate of silver has great antiphlogistic 
powers, as well as caustic properties, especially when applied to the 
skin and mucous membranes. Iodine also exerts a somewhat similar 
influence. 

Counter-irritation. — By means of dry cupping, blisterS; setons, 
issues, caustic, and actual cautery. 

ABSCESS. 

An abscess is a collection of pus in a natural or preternatural 
cavity, and may be either acute or chronic. 

ACUTE ABSCESS. 

Is frequently called plilegmon, when occurring in the subcu- 
taneous cellular tissue. Commencing with all the symptoms of 
inflammation, — fever, pain, redness, and swelling. The centre is 
firm, with oedema surrounding it. The formation of pus is indi- 
cated by rigors, an abatement of the fever, and a feeling of weight, 
tension, and throbbing. The centre softens, which is termed 
pointing, and fluctiiation can be felt. There is a natural tendency 
to the discharge of pus, which is more apt to be towards the skin. 
It is less apt to open into serous than into mucous membranes. The 
matter having been discharged, the pyogenic membrane lining the 
cavity becomes covered with numerous small, red, vascular emi- 
nences, called gramdations. They are formed by the organization 
of lymph. 



ABSCESS. 21 

The cavity contracts and fills up with granulations. A white 
pellicle extends from the circumference, gradually covers the whole 
surface, and becomes organized into a new cutis and cuticle, called 
a cicatrix. At first the cicatrix is thin, red, and less vascular ; it 
afterwards contracts and becomes paler. 

The causes of abscess are mostly idiopathic; it occurs fre- 
quently after fevers ; it may, however, be caused by blows, foreign 
bodies, &c. 

Treatment. — The indications are, in the first stage to produce 
resolution, and prevent the formation of matter. After it has formed, 
the indications are to cause its evacuation, and induce granulation 
and cicatrization. There should be cold applications, and leeches 
applied to the part, purging, and low diet. When matter is formed, 
the applications should be warm fomentations and poultices. Poul- 
tices may be made of bread, Indian meal, or ground flaxseed softened 
with water; they should be large and light, and renewed frequently ; 
they relax the skin, promote perspiration, soothe the pain, encourage 
the formation of pus, and hasten its progress to the surface. Lint 
soaked in warm water may answer for a substitute. 

Abscesses need not be opened if they point, and are pyramidal, and 
do not enlarge in circumference, but may be allowed to burst them- 
selves. But they should be opened when they are beneath tendons, 
fascia, or the thick cuticle ; when caused by the infiltration of urine; 
when in loose cellular tissue, with a tendency to burrow ; when near 
a joint, or under the deep fascia of the neck, — where it is desirable 
to obviate the scar made by the abscess opening spontaneously. The 
best instrument for the purpose is a straight-pointed, double-edged 
bistoury, by which the opening can be enlarged to any extent. The 
matter should not be forcibly squeezed out, but allowed to exude 
gradually into a poultice. By introducing a tent the edges are 
prevented from uniting. 

Abscesses are sometimes absorbed, especially those in glandular 
structures and venereal cases. This can be promoted by leeches, 
mercurial ointment, and remedies adapted to increase the general 
health. 

CHRONIC ABSCESS. 

Is the result of a low degree of inflammation, and is often unsus- 
pected. It is lined by a cyst, and the pus is serous or curdy. Some- 
times the matter is concrete. Is most apt to occur in weak and 
scrofulous habits, and is usually fi-ee from pain, redness, swelling, 
&c. It may, however, become exceedingly largo, and from disten- 
sion, inflame, ulcerate, and discharge. 

Treatment. — Improve the general health, and promote absorption 
by means of mercurial plasters, blisters, and iodine frictions. \i it 
cannot be absorbed, it must be opened with care ; a small, super- 
ficial abscess should be opened freely at once, the cavity injected 



22 SURGERY. 

with a stimulating solution , and pressure applied by means of com- 
press and bandage. If the matter is not freely evacuated^ great in- 
jury results from the effect of air on the contained pus; putrefying, 
the product — hydrosulphate of ammonia is absorbed, and the patient 
becomes typhoid. When the abscess is large, the opening should 
be small and valvular, so as to prevent the introduction of air ; or, 
the opening may be healed after a portion of the matter has escaped, 
and another made ten days afterwards ; or, the part may be kept 
constantly immersed in water. 

ULCERS. 

Ulcers are breaches of continuity of surface, the destruction 
being caused by disease or unrepaired injury. The following classi- 
fication will be found to include the great majority of ulcers. 

SIMPLE OR HEALTHY ULCER. 

In this we have an exemplification of granulation and cicatriza- 
tion. The surface is covered with a thick, creamy, yellow pus, not 
too profuse, and inodorous. The granulations are small, pointed, 
florid, sensitive, and vascular. "When they reach the level of the 
skin, cicatrization commences. The edge swells a little, and then 
is covered with a white pellicle of lymph, which is converted into 
cuticle. 

Treatment, — The plan of the treatment is simply protective. Pus 
is the natural protection to these granulations ] if, however, it col- 
lects, it becomes a source of injury, increasing ulceration. The air 
acts as a stimulus, and may cause too great inflammation. Hence 
the propriety of dressing. It should be lint dipped in tepid water 
or some simple cerate; water dressings are now preferred. The 
dressing should only be removed for the sake of cleanliness and re- 
moving the fluid pus ; but care should be taken not to wash the 
surface too freely, else the progress of cicatrization is delayed by 
the removal of lymph which may be mistaken for pus. 

WEAK ULCER. 

If the granulations are too luxuriant, becoming pale and flabby 
and long, they should be treated by an astringent wash, such as a 
solution of sulphate of zinc or copper ; or they may require an 
escharotic, such as solid sulphate of copper or nitrate of silver ; or 
a scab may be formed by exposure to the air, or spreading fine lint 
upon the surface ; at the same time a generous diet will be bene- 
ficial. 

SCROFULOUS ULCERS. 

These occur in debilitated constitutions, and usually in clusters ; 
most frequently upon the neck and joints. They originate in the 
cellular tissue, beneath the skin. At first, there is hardening, with- 



ULCERS. 23 

out pain^ then swelling, followed by imperfect and slow suppuration ; 
the skin becomes blue and thin, and the aperture for the discharge 
has ragged edges, revealing a dirty gray surface, with no granula- 
tions; the integument is soon undermined, and the ulcers communi- 
cate. The pain is slight, and the discharge is thin and serous. The 
system sympathizes and the result may be hectic. 

Treatment. — Constitutional remedies should be steadily perse- 
vered in. Active measures must be taken to get ridVjf the soft in- 
filtrated tissue surrounding, by escharotics ; caustic potash must first 
be freely applied, and then a poultice ; upon its removal a slough 
will be found to have separated, and the surface to be firm and vas- 
cular, covered with healthy granulations. The sore may then be 
treated as a healthy one, unless a relapse occur, when the applica- 
tion should be repeated. The constitution must be sustained, and 
the cicatrix supported by a bandage ; otherwise it may ulcerate^ es- 
pecially if it is bluC; soft, spongy, and elevated. 

INDOLENT ULCER. 

This is the most common of all ulcers, and occurs most frequently 
in the lower extremity and in old persons. It is owing frequently 
to a healthy sore having been neglected or badly treated. Its surface 
is smooth, glassy, concave, and pale. The discharge is thin and 
serous. Its margin is elevated, round, white, and callous, resem- 
bling a cartilaginous ring surrounding a mucous membrane. The 
surrounding integument is swollen, hard, and of a dusky red colour. 

It has little sensibility, and the patient is apt to let it go unnoticed, 
unless by accident, exposure^ or over-exertion, it inflames and be- 
comes painful. 

Treatment. — At first a poultice will be serviceable by cleansing 
the sore and diminishing the inflammation and pain which usually 
precede the application for relief, which a purge and rest will assist 
in producing. The surface should be lightly touched with nitrate 
of silver or nitric acid, in order that healthy granulations should 
sprout ; or, pressure may be employed to produce the same efl'ect by 
means of strips of adhesive plaster and bandages. Small doses of 
opium are also useful in maintaining the capillary circulation. 

IRRITABLE ULCER. 

This has been defined as possessing an excess of organizing action, 
with a deficiency of organizable material. It is superficial, having 
an unequal surface of a dark hue, and often covered with tenacious 
fibrin. It occurs most frequently near the ankle. The edges are 
thin, serrated, and everted. The discharge is thin, acrid, and bloody. 
It is very sensitive, attended with great pain, and produces often 
peevishness of disposition. 

Treatment. — Rest, elevation, and relaxation of the part. Nitrate 



24 SURGERY. 

of silver produces a sedative and antiphlogistic effect. This should 
be followed by a light poultice, or warm-water dressing, or, if there 
is great pain, fomentations of the infusion of opium, conium, or 
belladonna. 

PHAGEDENIC ULCER. 

This is of an irregular form, with ragged, abrupt edges, and 
uneven brown surface, looking as if gnawed by the teeth of an 
animal. It is attended with burning pain, and great constitutional 
disturbance. 

It frequently assumes a sloughing form, as in hospital gangrene 
and cancrum oris, when the discharge is extremely foetid. 

Treatment. — Should be both constitutional and local. Fresh air 
and good diet are all-important ; the secretions must be corrected 
and a Dover^s powder given at night. Locally, there should be ap- 
plied active escharotics, such as nitric acid, nitrate of mercury, &c., 
followed by warm poultices ; these may be superseded by warm solu- 
tions of the chloride of lime or soda. Mercury must never be given, 
especially in cases of a venereal taint. 

VARICOSE ULCER. 

This is dependent upon a varicose condition of the veins, and 
usually occurs in the leg, just above the ankle. They are oval and 
superficial, and attended with deep-seated, aching pain. They are 
indolent, and usually moist upon the surface. 

TreatTiient. — The cure must depend upon removing the disease of 
the veins. _ Great relief will be found in the constant use of cold 
water, rest, regular bandaging, or laced stockings. 

Certain ulcers are not to he healed ^ for example, when an ulcer 
has been stationary for years, when the patient is old, gouty, or a 
high liver ; it may be looked upon as a safety valve, and any ten- 
dency to unite as indicative of impaired health. The sudden cessa- 
tion of a drain of pus might be followed by hemorrhage, apoplexy, 
or inflammation of some important organ. 

ERYSIPELAS. 

Erysipelas is an inflammation of the skin and subcutaneous cel- 
lular tissue, having a tendency to spread. 

The cutaneous form is characterized by redness, elevation, and 
burning pain ; compression produces pale dimples, which soon dis- 
appear, and the cuticle vesicates. It usually terminates in a week 
or two, but may return to some other part. 

The phlegmonous or cellulo-cutaneous form is more severe. The 
swelling is greater, the colour darker, and the pain more severe. 
Thin, ichorous pus is formed, which infiltrates the cellular tissue, 
and thus ulcerations and sloughs follow. The constitution sympa- 



ANTHRAX, OR CARBUNCLE. 25 

thizes ; at first the fever is high, then there are signs of hectic, and 
at last prostration and collapse. 

When it affects the head or throat, producing coma or dyspnoea, 
and when it occurs in feeble, old, or intemperate persons, there is 
great danger. 

The causes may be fatigue, foul air, intemperance, epidemic in- 
fluence, contagion, and injuries. 

Ti^eatment. — This must be adapted to the age d^uA" constitution of 
the patient ; the young and plethoric will require most active anti- 
phlogistic treatment constitutionally, whilst the old and broken down 
will need stimulants and tonics. In most instances, bleeding will 
be useful, followed by saline purgatives and diaphoretics. In highly 
inflammatory cases, an emetic administered early will also prove 
serviceable. 

Bark will be necessary in the latter stages, if there is debility ; 
opium will allay the restlessness at night. 

The local measures most useful are leeches, punctures, cold lotions, 
if the pulse is good ; and mercurial ointment, or nitrate of silver 
applied to the surface. Extension of the disease may be prevented 
by strips of blistering plaster, encircling the part. 

Deep incisions are to be made in case there is pus collected under 
the skin. 

Chronic, or habitual erysipelas, is best treated by alteratives and 
aperients. 

FURUNCULUS, OR BOIL. 

Boils occur most frequently in the young, and in those of plethoric 
habit, and in those parts where the skin is the thickest. They are 
usually gregarious, and depend upon derangement of the primae 
viae, and frequently succeed eruptive diseases. 

The swelling is of a conical shape, having a hard, red, and pain- 
ful base, and a yellow apex. If left to itself it bursts and dis- 
charges pus, and a core or slough of cellular tissue. When com- 
pletely emptied the heat and pain subside. 

Treatment. — Poultices and warm fomentations should be applied 
early ] as soon as pus has formed a free incision must be made ; and 
the granulating wound dressed in the ordinary way. 

ANTHRAX, OR CARBUNCLE. 

This is a serious disease ; it is a solitary inflammation of the cel- 
lular tissue and skin, presenting a flat spongy swelling of a livid 
hue, and attended with dull burning pain. It varies in size, and 
its progress is slow. 

The constitutional symptoms are asthenic throughout, and the 
attendant fever is apt to become typhoid ; prostration and delirium 



26 SURGERY. 

often terminate the case. It most frequently attacks high livers of 
an advanced age. 

Treatment. — A free and early incision will evacuate sanious pus 
and fetid sloughs ] this is to be followed by applications of caustic 
potash, in order that the dying parts may be thoroughly removed. 
Poultices and warm fomentations will clean the surface, and give 
rise to healthy granulations. Tonics and stimuli, such as bark, 
brandy, ammonia, are early required, particularly if the carbuncle 
is large, and system debilitated. 

PERNIO, OR CHILBLAINS. 

This is an affection of the skin, produced by sudden alternations 
of cold and heat, most commonly affecting the toes, heels, ears, or 
fingers. It is attended with itching, swelling, pain, and slight red- 
ness at first ; it may afterwards become of a livid hue, with vesica- 
tions and ulcerated fissures, which are difficult to heal. 

Treatment. — There is a great variety of applications in domestic 
use for this disease, and some of them of the most opposite character. 
The most serviceable remedy under all circumstances, but particu- 
larly when there is ulceration, is the nitrate of silver. Temporary 
and soothing relief is produced by cold applications. 

FROST BITE. 

Severe exposure, combined with exhaustion and fatigue, irresist- 
ably induces sleepiness, which, if yielded to, is followed by coma 
and death. When a part of the body is frost-bitten it becomes 
contracted, pale, and insensible. It may take place without the 
consciousness of the patient; without care it terminates in gan- 
grene. 

Treatment. — Produce moderate reaction^ which will restore cir- 
culation and sensibility, taking care that it be not excessive, which 
would lead to dangerous inflammation. First rub the part with 
snow, and then with cold water in a room without fire. For the 
comatose condition of the body produced by cold, also use friction 
with snow, in a cold room, afterwards substituting flax or flannel ; 
gradually giving warm and stimulating drink, such as wine and 
water. 

BURNS AND SCALDS. 

There are three principal divisions of these injuries, which may 
be produced by hot fluids, vapour, flame, or solids. 

1st. Those which produce mere redness and slight inflammation, 
terminating in resolution, and perhaps desquamation. 

2d. Those causing vesications of the cuticle, which often dry up 



WOUNDS. 27 

and heal; but if the cutis has been injured and inflamed, suppura- 
tion and ulceration result. 

3d. Those causing the death of the part, in which there is not 
much pain, and which are followed by sloughs. 

Extensive burns, even if superficial, are very dangerous ; and 
those upon the trunk are more fatal than those of the extremities. 
The symptoms are paleness and shivering, with a feeble, quick 
pulse ; often prostration, coma, and death. The greatest danger is 
during the first four or five days, from collapse ; subsequently from 
an affection of head, chest, or abdomen, or from prostration. 

Treatment. — Bathing the part in cold water will mitigate the 
heat, pain, and inflammation ] afterwards it must be protected from 
the air by cotton, or some bland unctuous substance, care being 
taken to discharge the vesicles without removing the cuticle. Calm 
the nervous excitement with opium, and prevent sinking with wine 
and ammonia. Be careful of over stimulation, and promote the 
separation of sloughs by rest, poultices, and fomentations. Regulate 
the diet, and encourage granulations by water-dressings, saturated 
with salts of copper, zinc, or silver, or with chloride of lime. Con- 
traction of cicatrices is to be prevented by mechanical means, and 
the function of joints is to be retained by passive motion. 

AVOUNDS. 

Wounds are classified into incised, contused, lacerated, punctured, 
poisoned, and gunshot. 

INCISED. 

These are produced by sharp-edged instruments, and bleed freely. 
They heal in various ways; hy adhesion^ or Pinion hij the first inten- 
tion^ in which there is no suppuration. Fibrin is thrown out, and 
coagulating, becomes organized, and constitutes a new living struc- 
ture ; incorporated with the cut surfaces, it restores the solution of 
continuity in the solid parts. 

Wounds heal by growth^ whereby reparation is made, without 
inflammation and suppuration, as in ordinary nutrition. 

Wounds heal by the modelling process, which is somewhat similar 
to the last, the gap gradually filling up with lymph, and restoring 
the deficiency. 

Wounds heal by granulation, constituting union by the second 
intention, a process formerly described in treating of abscess. 

Treatment. — This consists in arresting hemorrhage, removing 
foreign bodies, bringing the edges together, and promoting adhe- 
sion. 

Hemorrhage is arrested by cold applications, elevated position, 
and compression, or, if an artery has been cut, by a ligature, or by 
torsion. 



28 SURGERY. 

Ligatures are usually made of silk or thread, and should be 
round or twisted, in order to divide the internal and middle coats of 
the artery. Animal ligatures are sometimes used on account of 
their speedy decomposition, and separation from the artery ; liga- 
tures of lead have also been used. 

Compression can be effected by the tourniquet, bandages, and 
pledgets of lint ; in lieu of a tourniquet a Spanish windlass may be 
used, which is made by tying a handkerchief around a limb, and 
twisting it tightly with a stick. 

Styptics are also used where the vessels are small, and the actual 
cautery when the hemorrhage cannot be arrested by other means. 
Foreign bodies, such as pieces of glass, clots of blood, &c., &c., are 
to be removed from the wound, and the lips brought together by 
means of adhesive plaster applied to surfaces cleanly shaved, and 
free from moisture. 

Sutures^ or stitches, are to be used only when the edges cannot 
be approximated by other means. An interrupted suture is made 
by passing a needle, armed with a single ligature, through both lips 
of the wound, which are then to be drawn together without any 
great straining, and secured by a double knot. These stitches are 
to be made at intervals of about an inch, but should not be made in 
any tendinous structure, or highly inflamed part. 

A twisted suture is made by transfixing the margins of the wound 
with a needle or pin, and passing around it. a waxed ligature in the 
form of the figure 8, by which means the edges are brought in con- 
tact ; the point of the pin, or needle, is to be protected with wax, 
and allowed to remain for several days. 

The continued J or glover^ s suture, is nothing more than the ordinary 
mode of sewing cloth or leather. 

CONTUSED AND LACERATED. 

These resemble each other; are attended with little hemorrhage, 
because the arteries are torn, and do not bleed so much as when 
cut. They are dangerous, because they are liable to inflammation 
and sloughing, and are often complicated with foreign bodies ] and 
they are more apt to produce constitutional disturbance and tetanus. 

Treatment. — Adhesion is impossible; suppuration must take 
place, and the dead parts be thrown off; the reparation takes place 
by granulation. At first it will be necessary to arrest hemorrhage, 
remove foreign bodies, bring the parts in apposition by strips of 
adhesive plaster, and apply water-dressings, or a light poultice, ac- 
cording to the condition of the patient. Cold and other antiphlo- 
gistic means, such as bleeding and purging, must be used cautiously 
when there has been a great shock upon the system, otherwise the 
vitality of the parts will be depressed, and the risk of gangrene 
increased ; but after fever and suppuration are established, the 



WOUNDS. 29 

usual means of combating inflammation may be employed. When 
the sloughs are numerous, and the discharge profuse, typhoid symp- 
toms will appear, especially if the patient be much reduced by 
depletion and rigid diet. 

PUNCTURED AND PENETRATING. 

These are inflicted by sharp-pointed instruments, and are ex- 
tremely dangerous, on account of the injury done to important parts, 
by opening vessels and cavities, and from the difiusion of purulent 
secretions, and the liability of tetanus. 

Treatment. — After ascertaining that the wound contains no foreign 
matter, apposition is efiected, and maintained by position, rest, and 
dressings, and the system placed under antiphlogistic regimen ; ad- 
hesion is to be expected, or reparation by granulation. There may 
be severe secondary symptoms arising from secondary hemorrhage, 
or confined purulent secretions; it may be necessary to apply a 
ligature upon the artery above the ulcerated wound; or, to open 
and dilate it for the exit of pus, or a foreign body before undis- 
covered. 

POISONED. 

These include bites and stings of animals, and the effects of dis- 
secting wounds. 

The stings of ordinary insects are not sufficiently severe to re- 
quire surgical aid, unless in great number, and in peculiar situa- 
tions. Children sometimes suffer with fever and headache, when 
stung in a number of places; and the suffocation produced by a 
sting in the pharynx is alarming. * • 

Treatment. — For the common sting of a wasp or bee, remove the 
sting of the animal with forceps, should it remain, and apply some 
stimulating application, such as turpentine, cologne water, or harts- 
horn. Hartshorn will probably give most relief, especially com- 
bined with cold applications. If there is faintness or depression, 
administer wine and opium. If the sting is in the fauces, use 
leeches internally and externally, stimulating gargles, and, if neces- 
sary, open the trachea. 

Spiders J especially the tarantula, scorpions, and serpents, inflict a 
most severe injury. The bite of the viper, cobra dc capcUo, and 
rattlesnake, is attended with great pain, swelling, constitutional dis- 
turbance, and death. In such wounds great caution must be used 
to extract the poison from the wound, and to prevent its passing 
into the circulation. Surrounding the limb with a ligature, bathing 
the wound with warm water, and sucking it, are all of use ; but tho 
application of cupping glasses, and scaritications, is the most certain 
method. 

The prostration of the system is to be treated with brandy and 



30 SURGERY. 

ammonia, and the pain to be relieved by opium. Various remedies 
are given internally, such as sweet oil and ammonia, but arsenic 
has a most decided preference; the celebrated Tanjore pills each 
contain a grain; the proper dose is fjj to fjij of Fowler's solution. 

Hydrophobia. — Hydrophobia is a disease brought on by inocu- 
lation with the saliva of a rabid animal, and characterized by inter- 
mitting spasms of the muscles of respiration, together with a pecu- 
liar irritability of the body and disturbance of the mind. 

The first symptoms in the dog are shyness, want of appetite, 
drooping of his tail and ears, a suspicious, haggard look, red and 
watery eyes, constant snapping at and swallowing straws, and lick- 
ing cold surfaces, such as stone and iron ; afterwards respiration be- 
comes difficult, viscid saliva flows rapidly, and there is inflammation 
of the fauces, and high fever. He is not always furious, nor does 
he always bite, unless irritated ; his gait is staggering, and he dies 
in convulsions, usually after the fifth day. 

The symptoms in man vary with constitution and habit, and usu- 
ally appear between five and ten weeks subsequent to the bite. 

The wound heals as usual ; after a time there is pain and itching 
in the cicatrix, which gradually increases, and ulceration follows. 
There is headache, restlessness, fever, and excitement of the ner- 
vous system. The mind is particularly clear and active; the me- 
mory strong, the imagination vivid, the countenance animated, and 
the eyes sparkling. This is succeeded by despondency, and the 
dread of fluids, great agitation, spasms, difficulty of breathing. 
Every attempt to relieve the burning thirst is followed by convul- 
sive contractions of the neck and throat ; sleepless despair, change 
of voice, croupy inspiration, and involuntary biting are the next 
symptoms. As the disease advances, the brain becomes more af- 
fected, and death is preceded by delirium. 

Treatment. — The recent wound should be treated by cupping- 
glasses and nitrate of silver. In not more than one case out of 
twenty does hydrophobia follow the bite of a rabid animal. The 
bite is much less dangerous when through the clothes. After the 
disease is established, nothing can be done with the prospect of 
cure ; although every remedy and mode of treatment has been re- 
commended. Palliatives and medicines which calm the nervous 
system and relieve pain may give some temporary relief. 

Dissecting Wounds. — These are followed by unpleasant results 
more frequently in those of a scrofulous temperament, or in those 
whose systems are exhausted by study or dissipation. 

The consequences may be a simple pustule, inflammation of the 
lymphatics, and typhoid fever, with diff'use abscesses. 

The pustule has not much elevation, is surrounded by redness, 
and attended with burning and itching. When opened it discharges 
a little, thin pus, and is soon refilled, the excavation gradually in- 



GUNSHOT WOUNDS. 31 

creasing. This may not be followed by constitutional symptoms, 
unless the health is very bad. 

The inflammation of the lymphatics is more apt to follow a small 
scratch or wound from examining recent subjects, especially those 
dying with peritonitis or any disease of serous membranes. The 
pain and swelling extend up the arm to the axilla, and there is fever 
and depression of spirits. The course of the inflammation can be 
traced along the lymphatics to the axillary glands, which often 
suppurate. 

Extensive abscesses and typhoid fever take place when the poison 
is very violent and the system much prostrated. 

Treatment. — The pustule will be managed best by a lye poultice, 
and then removing the coverings and touching the surface with 
lunar caustic. A simple incision or puncture for an ordinary pus- 
tule will not prevent the renewal of the matter. 

When the lymphatics are inflamed, the original wound is not 
always the most tender spot, nor is there the appearance of a pus- 
tule. Leeches, cold applications, poultices of Indian meal and rye, 
nitrate of silver, and tincture of iodine are useful local applications. 
Bleeding may be necessary when the inflammation and fever are 
very high. Free incisions prevent the formation of abscesses, by 
evacuating the serum and depleting the part. Spreading abscess of 
the cellular tissue is attended with typhoid fever, and very dange- 
rous. The system must be supported by stimulants and tonics, such 
as brandy and bark; opium will allay pain and restlessness, and the 
local dressing will resemble that for abscess in general. 

Fresh air, clean clothes, healthy skin, good diet, and regular 
habits will be found to be the best prophylactics. 

GUNSHOT WOUNDS. 

These include all injuries by fire-arms, and partake of the nature 
of lacerated and contused wounds. There is usually but little he- 
morrhage, unless a large vessel is injured. The nature and extent 
of the injury will vary with the distance, force, and character of the 
shot or slug producing it, and the part affected ; fracture, contusions, 
and perforations may require amputation. The aperture made by 
the entrance of the bullet often appears smaller than the bullet, and 
resembles an incised wound with inverted edges ; the aperture of its 
exit is larger, and has ragged and everted edges. The pain of a 
flesh wound is often so slight that it does not attract attention; but 
when a bone is broken or a nerve torn, the pain is severe. The 
shock upon the system is greater than in other wounds, and is partly 
corporeal and partly mental. Syncope and depression of spirits are 
very common attendants. 

The idea of injury resulting from the wind of a hall is erroneous. 



32 SURGERY. 

Injuries may result from spent balls, which, having a rotary motion, 
may roll over the surface without producing an open wound. 

The course of bullets is uncertain ; any obstacle, such as a button, 
a watch, or a bone, may occasion a most devious track. A ball may 
strike the forehead, and emerge at the occiput, or, striking the ster- 
num, lodge in the scrotum. A bullet may be divided into two 
parts by striking a sharp edge of bone ; or it may bury itself, and 
remain concealed for years, being enclosed in a cyst. 

When there is but one aperture, it is probable that the ball has 
lodged ; though it may have escaped upon the removal of the cloth- 
ing, if a portion of the clothing should have been carried before it 
into the wound; or, the ball may make a complete circuit, and 
escape by the aperture of entrance ; in this instance the track would 
be discovered by redness and swelling. When two orifices are in a 
straight line, it is not always to be inferred that the ball has escaped, 
for two balls may have entered opposite each other ; the character 
of the orifices will determine this point. A plurality of openings 
does not always imply a plurality of balls ; the same bullet may per- 
forate and escape, and perforate again. 

The wound partially sloughs and may produce abscess, erysipelas, 
hemorrhage, disease of the bones, hectic, or tetanus. 

Treatment — The general indications are to overcome the shock, 
remove foreign matters, adjust the parts, and place them in a com- 
fortable and relaxed position. 

A simple wound, made by a ball passing through some fleshy part 
should at first be sponged clean, and after hemorrhage has ceased, 
dressed with dry lint, secured by strips of plaster. A little wine 
and laudanum may be given if the patient is disposed to faint, or 
suffers much with anxiety and fear. In a few days there is inflam- 
mation and suppuration. The primary dressings are to be removed 
with warm water, and a poultice or the water dressing substituted. 
Care must be taken that the sloughs are readily thrown off, and that 
no sinuses are formed. The constitutional treatment should be 
moderately antiphlogistic ; consisting of purging, low diet, leeches, 
and perhaps bleeding ; an opiate at bedtime will allay pain and 
twitching. 

The presence of bullets and other foreign bodies can be detected 
by a probe, and they are to be removed by a forceps, the wound 
having been dilated, if necessary. If they are superficially lodged, 
they are to be cut down upon, extracted by a counter opening; if 
they are deep-seated and impacted, wait for the suppurative stage. 
When lodged in bone, they may be removed by a chisel or trephine, 
lest they produce caries or necrosis, although in many instances 
they have become encased and occasioned no inconvenience. 

The question of amputation will be settled by considering the 
liability of gangrene, the usefulness of the limb if retained, the age. 



TETANUS. 33 

habits, and strength of the patient, and the means at hand for carry- 
ing out the treatment. The latter consideration will justify more 
numerous amputations in military and naval than in civil surgery. 
The following circumstances make amputation necessary. 

When a limb is completely knocked off by a cannon-ball. If the 
bone is shattered and the joint endangered, it should be amputated 
above the joint. 

When the femur is fractured, and the femoral artery or vein, or 
the sciatic nerve is lacerated. 

When large joints are injured; but that of the elbow may often 
be excised. 

When the main artery is wounded, and gangrene has commenced 
and is spreading. 

TETANUS. 

Is a disease of the true spinal system, and is manifested by spasm 
and rigidity of voluntary muscles. 

When the muscles of the neck and face are affected, it is termed 
Trismus^ or locked jaw; when the muscles of the front, Empros- 
thotonos; when the muscles of the back, Opisthotonos ; bending to 
either side is termed Fleurothotonos. 

Tetanus may be either an acute or chronic disease ; the former is 
the most frequent in occurrence, and most formidable to treat ; the 
latter, apt to be partial, milder, and more subject to treatment. 

Traumatic tetanus follows a wound or injury, and is usually 
acute ; idiopathic tetanus is of spontaneous origin, and usually 
chronic. 

Acute traumatic tetanus is more frequent in hot climates, and in 
military practice, and may follow a slight bruise or puncture, espe- 
cially if some nerve has been injured. Intestinal irritation and 
atmospheric changes predispose to the disease. 

The symptoms may appear in a few hours, or in as many days ; 
at first there is stiffness and soreness about the neck and face, the 
contraction of the muscles causing a ghastly smile ; swallowing and 
mastication are difficult, the forehead is wrinkled, eyeballs are dis- 
torted, nostrils dilated, and the grinning countenance is expressive 
of horror. Respiration is rapid, the tongue protrudes, and saliva 
dribbles ; the sphincters are usually contracted, perspiration is pro- 
fuse and of a peculiar odour; the pulse at first may be strong and 
full, but soon becomes weak and indistinct. The mind is clear until 
just before death, which generally takes place in a few days. 

Treatment. — The indications are to remove all sources of irrita- 
tion, and diminish the spasm. The wound is to be cleansed from all 
foreign bodies, pus to be discharged by a free incision, if necessary, 
and warm anodyne poultices and fomentations are to be applied. 
Excision of the wound, or division of the nerve leading to it, has 



34 SURGERY. 

been practised with great benefit. Bleeding should be employed 
with great care, and purgatives combined with mercury are always 
of advantage. Opium is almost indispensable, and may be used 
externally and internally. Camphor, musk, assafoetida, and tobacco 
are also of use as antispasmodics. 

Chronic tetanus is seldom fatal, and frequently idiopathic; it 
lasts several weeks, and should be treated by the shower-bath, 
tonics, and electricity. Ether or chloroform may be used with 
advantage. 

DISEASES OF BONES. 

CARIES. 

Caries is an unhealthy inflammation of the bone, attended with 
softening, and leading to suppuration and ulceration. The bone has 
its cells filled with serous, and often with scrofulous fluids, and 
when dried has a spongy and worm-eaten appearance, and resembles 
a lump of sugar after being dipped in hot water. The disease most 
frequently attacks the thick bones, and the extremities of long 
bones; and it may result from local injury, or simply from consti- 
tutional causes, such as scrofula, or eff'ects of mercury. It is 
attended with pain and swelling, and after ulceration there is a 
foetid discharge containing portions of bone. 

Treatment. — The constitutional treatment consists of fresh air, 
tonics, and alteratives ; and the local treatment in removing those 
portions incapable of repair, and endeavouring to establish healthy 
granulations. Sometimes it may be necessary to remove loose por- 
tions of bone which are disintegrated, and to apply escharotics to 
the surface. 

CAHIES or THE SPINE. 

This occurs most frequently in children, and in persons of a 
scrofulous temperament. At first there is a sensation of numbness 
in the lower extremities, languor, and a stumbling gait. The patient 
usually sits with his legs drawn up under the chair, has a constric- 
tion of the chest, and derangement of the digestive organs ; in a 
short time paralysis ensues, and there may be a pointing of matter 
at some portion of the spinal column, most frequently about the 
dorsal vertebrse. The bodies of the vertebrae are softened and com- 
pressed, and thus a curvature takes place ; the convexity of which 
is most frequently directed posteriorly. Many die from fever and 
irritation, and recovery is usually attended with deformity. 

Treatment. — Absolute rest upon a mattrass, attention to the 
general health, counter-irritations over the tender point, by means 
of blisters and issues, and in the early stages, leeching. The diet 



MOLLITIES OSSIUM. 35 

should be light and nutritious, and a laxative administered occa- 
sionally. 

NECROSIS. 

This signifies the death of the bone, which is often enclosed in a 
case of new bone". When a superficial layer is affected it exfoliates; 
the dead portions thrown off are termed sequestra. It occurs at all 
ages, and most frequently in the compact bones; the immediate 
cause, is inflammation of the periosteum. It is attended with swell- 
ing, and a discharge of matter through openings in the case of new 
bone, which are termed cloacce. The pain is deep-seated, long-con- 
tinued, and very severe. 

Treatment. — This is principally local, although constitutional 
remedies may be given to allay pain. The great object is to faci- 
litate the escape of pus and the sequestra ; it is often necessary to 
enlarge the cloacse by a saw or trephine, and to dilate the sinuses 
with lint. Amputation may be necessary in case the joints are in- 
volved. 

EXOSTOSIS. 

This is a tumour formed by an excessive and irregular growth ol 
bone. The shape varies, being sometimes broad, and sometimes 
spiculated. The structure is healthy, and it may cause no incon- 
venience, unless it interferes with an artery, muscle, or joint. 

Treatment. — The object is to produce absorption, by means of 
mercury, iodine, blisters and leeches ; but since these usually fail, 
it is necessary to resort to an operation. This may be performed 
by a saw or trephine. Scraping off the periosteum is also recom- 
mended. 

ERAGILITAS OSSIUM. 

This is a brittleness of bones, occurring frequently in youth, but 
oftener in old age. The proportion of earthy matter is relatively 
but not actually increased. The cancellated structure is filled by 
an oily substance, and surrounded by a thin, brittle lamella. This 
degeneration follows long confinement, intemperate habits, and 
rheumatic and cancerous affections. A hasty step, turning in bed, 
or tripping on a carpet, may produce fracture. 

Treatment. — In old persons all that can be done is to guard 
against any accident, and to enjoin a nutritious diet and salubrious 
atmosphere. In children, care should be taken to overcome a 
scrofulous constitution by tonics and good diet, and to treat the frac- 
ture as usual. 

MOLLITIES OSSIUM. 

This is a deficiency of the earthy matter of bones, and hence 



36 SURGERY. 

they are soft and pliable. This disease occurs in adults, and its course 
is rapid ; the general health is impaired ; flesh, spirits, and strength, 
diminish daily. The bones are light, soft and greasy, and often 
consist of an external shell, filled with a soft, greasy matter. The 
cause is obscure ; phosphatic deposits are found in the secretions. 

Treatment. — This is merely palliative^ for the disease is in- 
curable. 

RICKETS. 

This is an original defect of the skeleton, peculiar to youth and 
scrofulous temperaments. The bone is changed in its structure, be- 
coming soft and pliable, as in mollities ossium. The cancellated 
structure predominates, the cells being filled with a reddish oily fluid. 
The flat bones are often thickened, and the long bones atrophied in 
the shaft. This disease gradually increases with age, and hence 
great deformity, and curvatures of limbs must necessarily occur. 
In adult life, the general health may be regained, and the patient, 
though a confirmed and unseemly dwarf, weak and puny in his boy- 
hood, may prove a healthy, muscular, and active man. 

Treatment. — Improvement of the general system by diet, exercise, 
proper clothing, and tonics. Mechanical apparatus, properly con- 
structed, may be of service in preventing permanent deformity. 
Those articles of diet which are readily converted into lactic acid, 
such as sugar, starch, gum, milk, &c.j should be avoided, and animal 
food of easy digestion preferred. 

SPINA VENTOSA. 

This is a swelling, usually of considerable extent, involving the 
whole circumference of the bone, and has a regular surface. In 
most instances, it is a bony shell, containing one or several cavities, 
filled with an ichorous fluid, clotted blood, and portions of carious 
bone. It is preceded by severe pain, and external injuries and 
constitutional causes may give rise to it. It is difficult to cure, 
especially in adults. 

Treatment. — When the tumour is small, the cure is to be effected 
by means of puncture, satisfactory evacuation, external support, and 
internal stimulation of the cavity. If the tumour is large, and the 
general health affected, amputation will be necessary. 

OSTEO-SARCOMA. 

This is a tumour, composed partly of bone and partly of flesh, and 
is usually considered of a malignant nature. A dissection of the 
tumour presents a dense, pearl-coloured membrane, covering the 
surface, and adhering closely to the bone ; above this membrane the 
muscles are thin and spread out, so as to cover an extensive surface, 



FRACTURES. 



having lost their colour. Upon opening the tumour^ it will be found 
to contain cells divided by spiculge of bone^ and materials resembling 
flesh, jelly, and fat. It is attended v^ith deep-seated pain, and at 
last bursts, assuming a cancer-like ulceration. 

Treatment. — At first, leeches, cold applications, and anodynes, 
may give temporary relief, but no permanent benefit can be expected 
without its removal; and even after amputation, it frequently attacks 
the stump. 



Idren. 
knee ; 



Fig. 1. 



COXALGIA. 

This is a disease of the hip-joint, common to scrofulous chi 

Symptoms. — At first there is slight pain, referred to the 
lameness, and stumbling in walking ; tender- 
ness in the groin, and pain is produced by 
pressing the head of the bone suddenly 
against the acetabulum ; apparent lengthen- 
ing of the limb. This apparent increase of 
length is owing to a depression of the pelvis 
of the diseased side, the weight of the body 
being supported on the opposite limb. 

If the disease is not arrested, destruction 
of the head of the bone and acetabulum re- 
sults, and the femur is drawn up, constituting 
a spontaneous luxation. Often an abscess 
forms, and opens externally. The toes may 
be turned inward or outward. 

Treatment. — Perfect rest upon a mattrass, 
as in caries of the spine, the limb being con- 
fined in a carved splint. Cups and leeches, 
over the joint, will be useful at first; subse- 
quently, more benefit will be derived from 
counter-irritation by blisters, setons, and 
issues. Purging with jalap and cream of 
tartar, tonics, and iodine, are the constitu- 
tional remedies. It may require months or 
years to efi'ect a cure. 

FRACTURES. 

Fracture is a solution of continuity of a bone, produced by ex- 
ternal violence, or muscular contraction. Fractures arc divided into 
oblique, transverse, and longitudinal, according to the direction. 
Simple fracture is a mere separation of the bone into two parts; 
compound^ implies an open wound, communicating with the frac- 
ture; commdnutcdy when the bone is broken into nunun*ous frag- 
ments; and complicated J when attended with luxation, laceration of 
large vessels, &o. 




88 SURGERY. 

The signs of fractures are deformity, preternatural mobility, cre- 
pitation, pain, swelling, and helplessness of the part. Old age, and 
certain diseases of the bone, predispose to fractures ; in cold weather, 
they are more numerous, on account of the increased muscular ex- 
ertion necessary in walking, where there is ice. Indirect violence 
may occasion fracture, when a force is applied to the two extremi- 
ties of a bone, which gives way between them. Deformity may be 
produced by an angular derangement, or a derangement in the direc- 
tion of the axis, the diameter, or the circumference of the bone. 
Bent bones are occasioned by a few of the psseous fibres giving 
way upon the convexity of the curve. The process of reparation 
is more rapid in the young, and also takes place sooner in a small 
than in a large bone. Danger results, according to the site of the 
injury, the nature of the fracture, and the state of the system. The 
mode of reparation is attended by the following changes : extravasa- 
tion of blood ; after this is absorbed, the liquor sanguinis is effused, 
and assumes the position which the blood occupied; this consoli- 
dates ; the serous portion is absorbed ; the fibrin remains, and be- 
comes organized. This period of plastic exudation lasts for eight or 
ten days, and then becomes cartilaginous. This mass contracts, in- 
creases in density, and gradually becomes bone. The ossification 
advances from the periphery. The fractured extremities are now 
surrounded by a bony case, termed the provisional callus ; after 
which continuity is truly restored by the formation of what is called 
definitive callus, which takes place between the fractured extremities ; 
and, finally, the provisional callus is absorbed. 

Treatment. — This consists of two parts ; first, reduction, which 
is to be effected gradually by extension and counter-extension, over- 
coming muscular contraction, and coaptating the extremities ; se- 
condly, retention, which is effected by keeping the limb in such a 
posture as will relax those muscles which would be likely to cause 
a displacement, and by applying such mechanical means as will 
prevent motion ; these means consist of splints, which are variously 
constructed of wood, pasteboard, or metal, and applied by means of 
bandages or rollers ; they should be light, and always of such a 
length as to command the neighbouring joint ; the inner surface 
should be padded or lined, in order to prevent chafing. After being 
dressed, the part should be laid upon a pillow, and not disturbed, 
unless there should be inordinate swelling of the limb, when the 
bandage should be loosened. Bandages soaked in gum or starch, 
have recently been used, in place of splints. Under certain circum- 
stances, this dressing is admirable, but an indiscriminate employ- 
ment tends manifestly to injury ) on account of the swelling of the 
limb, it produces pressure, which may occasion ulceration or slough- 
ing. It is called the immovable apparatus. 

The diet should be watched, and antiphlogistic means resorted to, 



FRACTURE OF THE LOWER JAW. 89 

if 'necessary. At the end of three to six weeks, the provisional 
callus is complete, and the substitutes for this splint of nature can 
be discontinued; the use of the part must be resumed gradually, 
especially in the lower limbs. 

FRACTURE OF THE NOSE. 

The nasal bones are usually fractured by a fall, a violent blow, 
or kick of a horse, or some direct application of force. This frac- 
ture is often attended by injury of the brain, and followed hj caries 
and exfoliation. 

Treatment. — This consists of antiphlogistic means, such as 
leeches, cold applications, and rigid diet, to remove swelling and in- 
flammation, and the adjustment of the fragments; which can be ac- 
complished by a catheter, probe, or dressing forceps. The nose 
should not be plugged with lint, unless to check profuse hemor- 
rhage. The parts may be retained in apposition by compresses and 
rollers. 

FRACTURE OF THE MALAR AND SUPERIOR MAXILLARY BONES. 

These can only occur by the most direct violence, or gunshot in- 
juries, and are usually attended with crushing and wounding of the 
soft parts ; severe inflammation and nervous symptoms may come on, 
and the brain may also be aff"ected. There will be great pain and 
difficulty in chewing. 

Treatment. — If there is no displacement, there is nothing to be 
done but to subdue inflammation, and keep the parts quiet. If the 
alveolar processes are loosened, they must be pressed into their 
places, and the mouth kept shut, and the patient nourished by fluids. 

FRACTURE OF THE LOWER JAW. 

This may occur in the base of the jaw, in the ramus or pro- 
cesses; and in children it may take place at the symphysis. The 
most frequent seat of fracture is between the chin and the in- 
sertion of the masseter muscle ; the longer fragment and the chin 
are depressed. In double fractures, the chin alone is depressed. 
There is pain, swelling, inability to move the jaw, irregularity of 
the dental arch, crepitus, and frequently hemorrhage and deafness. 

The diagnosis of fracture of the ramus and condjde is often ob- 
scured by swelling ; the neck of the condyle is drawn forwards by 
the external pterygoid muscle, and crepitation will be perceived by 
the patient. 

Treatment. — The teeth serve as a guide in the adjustment of the 
fragments, and the upper jaw acts as a splint in the retention. A 
compress and a pasteboard splint, retained by a suitable bandage, 
will retain the parts in apposition ; and the patient is to be fed by 



40 SURGERY. 

gruels and soups^ through the interstices of the teeth. The union 
is rapid; and there is usually but little deformity. 

FRACTURE OF THE SPINE. 

This is attended with serious injury to the spinal cord, from com- 
pression, laceration, bruising, concussion, or from subsequent in- 
flammation and softening. When it occurs above the fourth cervical 
vertebra, death is almost certain, on account of the origin of the 
phrenic nerve which supplies the diaphragm. 

When the lumbar region has suffered, the symptoms are paralysis 
of the lower limbs, involuntary discharge of fasces, retention of 
urine, and frequently priapism. 

When the injury is in the upper dorsal or lower cervical region, 
there is, in addition to these symptoms, paralysis of the arms, diffi- 
culty of breathing, sluggishness of the bowels, and distension of the 
abdomen. In all fractures of the spine, the kidneys suffer, and bed- 
sores are apt to follow. 

Treatment. — Absolute rest upon a mattrass, low diet, and anti- 
phlogistic means, to prevent the formation of pus, and thickening 
of the membranes. The discharges of the bowels must be regu- 
lated, and the bladder relieved by the catheter ; counter-irritation 
and frictions will be useful in the latter stages of the case. The 
use of the trephine in this injury has not met with success, and will 
probably do more harm than good. 

FRACTURE OF THE PELVIS. 

Fracture of the bones of the pelvis can only be produced by the 
greatest violence. There is but little displacement, although great 
danger results from injury to the parts within. 

Treatment. — All that can be done is to place the patient at rest 
in an easy position, keep a catheter in the bladder, and make inci- 
sions, if urine or pus is extravasated in the perineum. The appli- 
cation of a broad bandage around the hips, will assist in preventing 
motion. 

When the crest of the ilium or the anterior superior spinous pro- 
cess is knocked off, the fragment is displaced inwards, and can be 
readjusted by the fingers. Fracture of the sacrum is longitudinal 
usually, and there is no displacement. The coccyx may be frac- 
tured by a kick, and is displaced inwardly : re-adjustment may be 
effected by the finger in the rectum. The acetabulum may be split, 
and injury of the neck of the femur may be simulated, though there 
is no shortening of the limb, and crepitus is felt by the finger in the 
rectum, when the pelvis is moved. 

FRACTURE OF THE RIBS. 

The ribs are very liable to fracture, which usually is in the mid- 



FRACTURE OF THE SCAPULA. 41 

die, when occurring from direct force, or force applied at each end. 
Displacement is seldom great, and is difficult to detect in fat per- 
sons. There is pain, swelling, and difficulty in breathing; crepitus 
is felt, when the hand is placed over the part during respiration or 
coughing; emphysema appears when the pleura is injured. 

Treatment. — If there is an angular projection of the extremities, 
a compress is to be applied over it; if there is a depression, a com- 
press is to be placed at each extremity; the chest is to^be surrounded 
by a roller, in order to prevent respiration by the intercostal mus- 
cles, and thus to keep the parts at rest. Inflammation and cough 
are likely to ensue, and must be treated by antiphlogistic means 
and anodynes. 

Compound fracture of the ribs is treated of, under the head of 
Wounds of the Chest. 

FRACTURE OF THE STERNUM. 

Fracture of this bone is rare, great violence being necessary to 
produce it ; injury usually is done to the thoracic viscera. The 
deformity is generally a depression, and the symptoms are great 
difficulty of respiration, pain, palpitation of the heart, and perhaps 
spitting of blood, and cough. Caries, or a pulmonary affection, 
often result from a fracture of the sternum or ribs in scrofulous 
habits. 

Treatment, — The local treatment consists of a compress and a 
roller, applied upon the same principles as in fracture of the rib. 
The general treatment must be adapted to the inflammatory condi- 
tions of the organs of the chest. Collections of pus and blood be- 
hind the sternum can be evacuated with a trephine, but the operation 
is often attended with unfavourable results. 

FRACTURE OF THE SCAPULA. 

The acromion process is sometimes fractured ; the shoulder loses 
somewhat of its roundness, the head of the humerus falls slightly, 
and there is a slight depression at the point of fracture. It is dis- 
tinguished from dislocation by mobility of the joint, and crepitation 
can be felt by rotating the head of the humerus. 

Treatment. — It may unite by bone, but generally it unites by 
ligament. It is to be kept in its place, by elevating and firmly fix- 
ing the OS humeri ; this is effected by placing a cushion between the 
side and the elbow, and retaining it by a roller, the elbow being 
carried a little backwards. If the pad be placed in the axilla, and 
the elbow be brought close to the side, the fragments will be sepa- 
rated ; but little inflammation follows, and bandages may • be re- 
moved in three weeks. In many individuals, the tip of the acromion 
process is slightly movable, being merely united by ligament. 

The neck of the scapula is rarely fractured, and it is liable to be 



42 SURGERY. 

mistaken for a dislocation ; the shoulder falls ; there is a hollow be- 
low the acromion^ from a sinking of the deltoid muscle ; and the 
head of the humerus can be felt in the axilla. It can be recognised 
bj the facility with which the parts are replaced, the falling of the 
head of the bone into the axilla, when the extension is removed, 
and by crepitation. 

Treatment — The first point is to carry the head of the humerus 
outwards, and the second to raise the glenoid cavity and arm. The 
former is effected by a thick cushion confined in the axilla by a 
bandage, and the latter by placing the arm in a short sling. Ten 
or twelve weeks are necessary to procure union, and a still longer 
time to recover the strength of the arm. 

The coracoicl may be fractured by direct violence ; the process is 
drawn downwards, by the action of the coraco-brachialis, pectoralis 
minor, and biceps muscles. There is pain, swelling, and crepita- 
tion in the part, and loss of power in the limb. 

Treatment. — This consists in making the fingers of the injured 
limb touch the shoulder of the opposite side, the position being 
secured by bandaging. 

The hody of the scapula may be fractured either vertically or 
transversely, and there is but little displacement, unless it is near 
the lower angle of the scapula. When the angle is fractured, it 
may be drawn forward and upward. 

Treatment. — This consists of a tight roller around the chest; the 
arm being placed in a sling. 

FRACTURE OF THE CLAVICLE. 

This fracture is frequent, and is usually produced by violence 
upon the shoulder, arm, and hand. It is generally oblique, and 
near the middle of the bone ; the part is painful and swollen, and 
every attempt at motion produces pain ) the shoulder is sunken, 
and drawn towards the sternum, and the acromial fragment is drawn 
downward by the weight of the arm, and forward and inward by 
the action of the subclavius muscle. The patient usually supports 
the arm with his other hand, to relieve the pressure upon the axil- 
lary plexus of nerves. The indications are plain, viz. : to elevate 
the shoulder; to keep it outward from the chest; and to draw it 
slightly backward. 

Treatment. — The mode of dressing this fracture is extremely 
various. Dessaidfs apparatus consists of a compress placed over 
the fracture, a wedge-shaped pad placed in the axilla, and retained 
by a roller which surrounds the chest. The elbow is to be brought 
to the side, and the arm and chest surrounded by circular turns of 
a' second roller, whereby the shoulder is elevated and drawn out- 
wards. A third and last roller commences at the armpit of the 
sound side, and being carried obliquely over the compress, descends 



FRACTURE OF THE HUMERUS. 



43 



the posterior portion of the arm, passes under the elbow, and ob- 
liquely upwards across the chest to the armpit, whence it started ; 
then over the back to the shoulder of the affected side, across the 
compress, down in front of the arm, under the elbow, and across 
the back to the sound armpit again. This bandage serves to retain 
the arm and shoulder in its elevated position. 

Fox^s apparatus consists of a wedge-shaped pad, secured by 
strings to a circular collar which surrounds the shoulder of the 
sound side, and a sling made of linen, which contains the forearm ; 
it elevates the shoulder, and, by bringing the elbow to the side, 
draws the shoulder outwards. 

Some use merely a pad and two handkerchiefs, which, if properly 
applied, can be made to fulfil all the indications. 

Some deformity almost always results. 



FRACTURE OF THE HUMERUS. 

The anatomical neck is the seat of fracture in young persons, and 
sometimes in old. There is little or no flattening of the shoulder, 
owing to the head of the bone remaining in its place ; the end of 
the shaft is directed obliquely upwards and forwards, and projects 
on the coracoid process; the arm is shortened, and 
crepitus is distinct after slight extension and coapta- Fig. 2. 
tion of the fragments. 

Treatment. — This requires a pad in the axilla, a 
splint on the fore and back part of the arm, a roller, 
and a sling for the hand, the elbow hanging free. 

Tlie Surgical Neck. — The upper fragment remains 
in its place, but its lower extremity inclines slightly 
outwards; the upper end of the lower fragment is 
drawn upwards and inwards under the pectoral muscle; 
the shoulder is round, the arm shortened, the elbow 
abducted, and there is crepitation upon adjustment. | j] 

Treatment.-^ K. pad is placed in the axilla; two 
splints secured by a roller ; the hand supported by a 
sling, and the elbow free. 

Fracture at the Neck may be accompanied with dis- 
location. This is recognised by the tumour in the ax- 
illa, formed by the head of the bone, which does not 
move when the shaft is rotated. 

Treatment. — An effort should be made to restore the 
head of the bone, and then to coaptate the extremities : / , y:^ 
this is often impossible ; then the extremity of the lower 
fragment should be brought to play in the glenoid ca- 
vity. A pad will be necessary in the axilla, and the 
same dressing as the last. A new joint is formed, and the motion 
of the arm are only partial. 



44 SURGERY. 

The shaft may be fractured at any pointy and is easily recognised 
"by crepitation; and when the fracture is just below the surgical 
neck, the lower extremity of the upper fragment is drawn inwards 
by the muscles inserted into the bicipital ridges, and the upper ex- 
tremity of the lower fragment is drawn outwards by the deltoid 
muscle. 

Treatment. — The reduction is easy, and the extremities may be 
retained in contact by four small splints placed around the arm, 
and secured by a roller, which, as in all other instances of its use in 
the upper extremity, must commence at the hand. The forearm 
should be suspended in a sling. 

The condyles are fractured in various ways. Either condyle may 
be fractured, most frequently the internal ; or, there may be a frac- 
ture between the two condyles, and another separating them from 
the shaft. These injuries are distinguished from dislocation at the 
elbow by mobility and crepitation. 

Treatment. — By a roller and two angular splints (PhysicFs), 
reaching to the hand from the middle of the arm. The angle of 
the splints must be changed to prevent anchylosis. Some deformity 
and stiffness often remain. 

FRACTIJB.E OF THE RADIUS AND ULNA. 

When both bones of the forearm are fractured at once, or when 
either bone is fractured near the middle, there is but little difficulty 
in the diagnosis, being easily recognised by the ordinary signs of 
fractures, such as pain, crepitus, swelling, and uselessness of the 
limb. 

Treatment. — The great object is to preserve the interosseous 
space ; for, if the fragments unite at an angle, supination and pro- 
nation will be prevented. The fracture is readily reduced by slight 
extension, and then the muscles should be pressed into the interos- 
seous space, in order to separate the two bones. 

Two splints, well padded on the inside, reaching from the elbow 
beyond the fingers, should be applied, and retained by a roller. The 
arm must be kept in a position between supination and pronation, 
and supported by a sling; after two or three weeks pasteboard 
splints or a starch bandage may be substituted. 

The RADIUS is more frequently fractured than the ulna, on ac- 
count of its articulating with the carpus, and thus receiving the 
weight of the body in falls, &c. When fractured near the middle 
there is but little deformity, the ulna acting as a splint. 

The neck of the radius is but rarely fractured, and the accident is 
difficult to recognise, especially when the muscles covering it are 
very large. It is to be discovered by fixing the head of the bone, 
and rotating the hand and forearm. 



FRACTURE OF THE RADIUS AND ULNA. 



45 



The lower extremity of the radius is often fractured, and fre- 
quently mistaken for a dislocation of the wrist. (Fig, 8.) 

Fig. 3. 




Fractures of the radius are to be treated upon the same principles, 
and by the same means as in other fractures of the forearm, unless 
the fracture should be through the articular surface of the carpal 
extremity of the radius. This latter fracture gives a peculiar defor- 
mity to the wrist, dependent upon a partial luxation of the carpus. 
In this instance, besides the ordinary splints, two small compresses 
are to be applied, one upon a prominence on the dorsal surface 
caused by the fragment, the other upon the projecting extremity of 
the radius on the palmar side. Of course these compresses will not 
be opposite to each other. Passive motion should be established in 



Fig. 4. 



Fig. 5. 




46 SURGERY, 

a week; for fear of anchylosis, and the loss of the pulley-like motion 
of the extensor tendons on the back of the radius. 

The ULNA is most frequently fractured below the middle of the 
shaft. The lower fragment approximates the radius by the action 
of the pronator quadratus^ and the other usual symptoms of frac- 
ture are evident. 

The olecranon process is often fractured by sudden violence, or 
muscular action. The fragment is drawn up upon the back of the 
arm by the triceps muscle, and the deformity is increased by 
flexion. The union is usually ligamentous. (Fig. 4.) 

The coronoid process is rarely fractured, and usually by inordi- 
nate muscular action of the brachialis anticus muscle, whose tendon 
is inserted in front of the base of this process. Dislocation back- 
wards by the action of the triceps may result. The union will be 
ligamentous. (Fig. 5.) 

Treatment. — Fractures of the shaft are to be treated by two 
splints and compresses, as are those of the radius. Fracture of the 
olecranon is to be treated by extending the elbow, placing a small 
splint in front of the joint, and securing it by a roller. The coronoid 
is to be treated by flexing the elbow, the fingers touching the oppo- 
site shoulder, applying a roller to relax the muscles and prevent 
their action, and keeping the forearm in a sling to the utmost. 

FRACTUEE OF TKE CARPUS, METACARPUS, AND 
PHALANGES. 

The bones of the carpus are seldom fractured. The injury is 
usually a compound one, and produced by direct force. 

The metacarpal bones are subject to simple fracture, which is 
easily recognised by pain, swelling, crepitus, &c. The treatment 
consists of coaptation of the fragments, and retaining them by 
means of two splints and interosseous pads, or compresses. 

The phalanges are liable to compound and simple fracture. Sim- 
ple fractures to be treated by two or four small splints, and a narrow 
bandage ; when several fingers are broken, a carved splint will be 
usefuL 

FRACTURE OFTHE FEMUR. 

The neck may be fractured within the capsule. This occurs most 
frequently in old persons, and in females, on account of the bony 
texture being more brittle in advanced life, and on account of the 
anatomical character of the neck of the femur in women. The 
accident may be produced by a slight fall, muscular contraction, 
blows, &c. The head of the bone remains in the acetabulum ; the 
lower fragment is drawn upwards by the muscles of the hip, and 
the foot is everted, owing to the action of the rotator muscles. 
The limb is shortened, the trochanter is one or two inches higher and 



FRACTURE OF THE FEMUR. 



47 



flatter than its fellow ; there is pain, crepitus, and want of voluntary 
motion. The arc which the trochanter, upon 
rotation, will describe, will be of a much smal- 
ler circle than that described by the rotation 
of its fellow. 

Union is possible, but improbable ; on ac- 
count of the difficulty of coaptating the frag- 
ments, the want of provisional callus, the frac- 
tured extremities being bathed in an increased 
quantity of synovia, and the feeble nutrition 
of the head of the bone through the round 
ligament. Yet, in a young person of good 
constitution, where the periosteum is not com- 
pletely severed, there may be bony union. 
Ordinarily, there results a false joint, thicken- 
ing of the capsule, partial absorption of the 
fragments, and the patient is lame for life, 
and requires a stick or crutch. Feeble old 
women may die from the shock of the injury, 
or from the irritation of pain and confine- 
ment. 

Treatment. — Extension and splints are un- 
necessary — the limb should be supported by 
pillows, and motion restrained. Care should 
be taken with reference to bed-sores, sloughs, 
&c. 

The neck may be fractured partly within and partly without the 
capsule, in which case the prospect of union is much more favour- 
able. Or, the extremity of one fragment may be driven into the 
cancellated structure of the other, constituting an impacted fracture; 
in these cases, crepitus is obscure, the displacement is slight, and 
there is considerable power and motion of the limb, and but little 
shortening and eversion. They are produced by great direct force, 
and are attended with great pain, swelling, and constitutional dis- 
turbance. The treatment may be successful in many instances, 
without the use of splints. 

The trochanter major may be fractured; the process is drawn 
upwards by the glutei muscles, and a space can be felt between the 
fragments. Approximation and retention are difficult, and the union 
generally ligamentous. The cure is to be effected by rest, position, 
and relaxing the muscles. 

Fracture of the condyles is a serious injury, especially when 
communicating with the joint. After the fragments are somewhat 
consolidated by rest and position, passive motion must be established 
to prevent anchylosis. 

Fracture of the shaft is c:isily recognised by shortening, cropi ta- 




48 SURGERY. 

tioiij &c. &c. The deformity is greater when it occurs in the upper 
part, especially when just below the tr enchanters, the lower end of 
the upper fragment being tilted forward by the action of the psoas 
magnus and iliacus internus muscles. 

Treatment. — The principles of treatment are, as in all fractures, 
coaptation and retention, but the means to effect it are various. 

The double inclined plane is a simple contrivance. The leg is 
secured to one plane, which furnishes the means of counter-extension 
and the thigh rests on the other ; the weight of the body produces 
the extension. 

Dessaulfs Apjyaratus. — Consists of an outer splint, three or four 
inches wide, reaching from the crest of the ilium to four inches be- 
yond the foot, each extremity having a hole in it; an inner splint 
reaching from the perineum to the sole of the foot, and an upper splint 
reaching to the knee. 

The counter-extension is made by a band in the perineum, which 
is secured to the upper end of the outer splint by means of the hole 
in it. The extension is made by a band or handkerchief applied to 
the ankle, and secured to the hole in the lower end of the outer splint. 
Listen uses only the outer splint, as represented in the figure. 

Fig. 7. 



D7\ Pliysich^s modification consists in an elongation of the outer 
splint, nearly to the axilla ; by this means counter-extension is made 
in a line more nearly parallel with the axis of the body, and a block 
was placed upon the inner side of the lower end of the same splint, 
below the foot, for the purpose also of preventing the line of exten- 
sion being oblique, which might produce pain and deformity. Bags 
of bran are placed on each side of the limb, so as to secure uniform 
pressure from the splints, and the whole is secured by bandages. 

Hagedornh Apparatus consists of one splint reaching from the 
hip to a foot-board. 

The counter-extension is made at the acetabulum of the sound 
side, and the extension by the foot of the injured side. The splint 
is first applied to the outer side of the sound limb, and the foot 
secured to the foot-board ; and the extension is made by drawing 
the foot of the fractured limb down to the foot-board, and securing 
it. This avoids the necessity of a perineal band, which may exco- 
riate. 



FRACTURE OF THE LEG. 49 

Dr, Gibson^ modification of this apparatus consists in an elon- 
gation of the splint as high as the axilla, which will prevent any 
lateral inclination of the body; and the application of a similar 
splint to the fractured limb. 

FRACTURE OF THE PATELLA. 

The accident may result from muscular contraction or direct vio- 
lence. It is sometimes attended with an audible snap and falling of 
the patient; the pain is not severe^ and a simple fracture is not dan- 
gerous. The limb is bent partially, and there is no ability to ex- 
tend it. 

The direction is usually transverse, and a separation of the frag- 
ments can be felt. There is no crepitus. Considerable swelling 
usually follows. 

Longitudinal fractu-res are rare, and are not attended by the same 
symptoms. 

Treatment. — Leeches and lotions should be applied to reduce 
swelling and inflammation, and then the limb should be extended, a 
roller and figure of 8 bandage applied to coaptate the fragments and 
compress the muscles of the thigh. A long splint, reaching from the 
ischium to the heel, applied to the back of the limb, will prevent 
motion. 

Bony union is not to be expected ; a strong ligamentous connexion 
is usually formed, which answers the purpose extremely well. Pas- 
sive motion should be made after five or six weeks. Sixty or 
seventy days will elapse before the limb can be used; and even 
then, caution should be taken that the newly-formed ligament be 
not broken. The patella of the opposite side is liable to fracture ; 
for it possesses the same structure which predisposed to fracture in 
the other limb, and there is increased muscular exertion of the sound 
limb. 

FRACTURE OF THE LEG, 

A frequent accident, occurring in one or both bones, from a fall 
or direct violence. The tibia is most frequently fractured, on ac- 
count of its exposed position, and sustaining the weight of the body. 
The fracture may occur at any part, but the deformity is greater, as 
it may be nearer the lower extremity ; if nearer the upper extremity 
the deformity may be slight and the patient even walk about. 

The fibula may be fi'actured by direct or indirect force. Little 
deformity results, unless the fracture is below its middle. When 
nearer the ankle, dislocation may be produced. The most frequent 
seat of fractux'e is from two to three inches above the malleolus. 
There is immediate lameness ; the foot is turned out ; crepitus is 
distinct, and a depression exists over the fractured part. 

Both hones are often fractured at once by falls or blows ; thoy 

6 



50 SURGERY. 

occur at the weakest points. The signs are evident : crepitus, pain, 
want of motion, &c. There is seldom any great shortening, and 
the deformity is readily reduced. 

Treatment. — "When both bones are fractured, when the tibia 
alone is fractured, or, when the upper part of the fibula is fractured, 
the best and most simple apparatus is the fracture-box and pillow. 
The fracture-box has a foot-board, to which the foot is secured by a 
bandage, thus preventing any lateral inclination. In lieu of this, 
two splints of the length of the leg, applied on either side of the 
pillow, will answer the purpose, care being taken to support the foot 
by a bandage or handkerchief. 

Fig. 8. 




Fractures of the lower end of the fibula are to be treated by Du- 
puy trends or Physick's apparatus ; which consists of a single splint, 
placed on the inner side of the leg, and reaching beyond the foot. 
It is provided with a wedge-shaped pad, which reaches only to the 
ankle, the larger end of which being applied to the internal malle- 
olus ; a bandage is carried over the ankle in such a manner as to 
produce inversion of the foot, making the sole of the foot approxi- 
mate the splint, and thus fragments are adjusted and the deformity 
removed. 

FRACTUBES OF THE BONES OF THE FOOT. 

The OS ccdcis may be fractured by great violence connected with 
the action of the sural muscles. The tuberosity will be drawn up 
by the tendo Achillis, and the patient is unable to stand. 

The treatment consists in overcoming the action of the triceps 
sur^, flexing the leg upon the thigh, and extending the foot upon 
the leg. The fragments are to be approximated by a figure of 8 
bandage. 

The astragalus is rarely fractured ; it may occur at the posterior 
part where the tendon of the flexor longus pollicis plays over it ; or 
it may oc-cur between the body and the head. In the first instance 
the foot will be inverted, in the latter but little deformity will occur. 

It can be treated successfully by a simple fracture-box. Should 
caries take place it may become necessary to extirpate it. 

The metatarsal bones and the phalanges are seldom fractured, 
unless the injury be complicated or compound. 



DISLOCATIONS. 51 



COMPOUND FRACTUllE. 

Unless a wound communicate with the fracture^ it is not com- 
pound. The wound may be produced by the means which broke 
the bonCj by the bone protruding, or by subsequent ulceration. 
G-reat danger may result from the shock^ hemorrhage^ tetanus, sup- 
puration, hectic, or typhoid fever. 

Primary amputation is necessary if the bone is^much shattered ; 
if a joint, especially the knee-joint, is opened; if large arteries are 
torn ; if the soft parts are extensively lacerated or bruised, particu- 
larly if the patient is old or enfeebled by disease. 

The treatment^ if it be determined to try to save the limb, will 
be to convert the fracture into a simple one, by arresting bleeding, 
removing pieces of bone, clots, &c., so the wound will heal without 
suppuration. To reduce the protruding fractured extremities, it 
may be necessary to saw off a portion ] to arrest the hemorrhage, it 
may be useful to envelope the parts in bran, or stuff the opening 
with lint, which must be removed as soon as suppuration occurs. 

The subsequent part of the treatment may require antiphlogistic, 
but more frecjuently tonic measures, such as bark, wine, good diet, 
&c., especially if the discharge is profuse. Secondary amputation 
may be necessary at last. 

DISLOCATIONS. 

Dislocation or luxation, is the removal of a bone from its articu- 
lating cavity. The ball and socket joints are most liable to the 
injury. 

The predisj^osinrif causes are the peculiarity of the construction of 
the joint, weakness or paralysis of the muscles, elongation of the li- 
gaments, particular position of the parts, accumulation of fluids in 
the joint, or diseases and fractures of the bones. 

The exciting causes are external violence ; such as blows, falls, 
&c., and muscular contraction. 

The symptoms are deformity, swelling, and a hollow where none 
should be, shortening or elongation, pain and immobility of the limb. 

The consequences are rupture of ligaments, effusion of blood and 
serum ; lymph coagulates, forms new adhesions, and fills up the old 
socket, and the head of the bone gradually accommodates itself to 
its new position, there always being some attempt to form a new 
socket; and thus considerable motion is subsequently acquired by 
the limb. 

Dislocation is to be distinguished from fracture by the absence of 
crepitus, the rigidity of the limb, the peculiarity of the deformity 
at the articulation, and by the absence of deformity after reduction ; 
whereas in fractures it will recur without being prevented by 
dressings. 

Treatment. — This essentially consists in overcoming the action 



52 



SURGERY. 



of the muscles which retain the bone in its unnatural position, and 
also in bringing the head of the bone into such a situation that the 
action of the muscles may draw it into its place. 

Constitutional means are often necessary to effect reduction in 
the larger joints, such as bloodletting, warm baths, emetics, in 
order to produce relaxation of the muscles. The local means are 
extension and counter-extension. The extension must be made gra- 
dually, in order to overcome the action of the muscles, and to place 
the head of the bone in such a situation as to be drawn into its 
place, and the extension must be withdrawn suddenly, in order that 
the muscles may have the effect by their contraction. 

The treatment subsequent to the reduction consists in maintain- 
ing the limb at rest, and applying leeches and cold applications to 
remove swelliDg and pain. Afterwards, if any stiffness remains, 
stimulating friction may be used. 

Subluxation implies a partial removal of the head of a bone from 
an articulating surface. Recent and old, are terms applied to luxa- 
tions with reference to the period which may have elapsed, and the 
changes which may have occurred by adhesions, &c. 

Compound Luxation. — This is connected with a wound in the 
integuments, fracture of bone, laceration of large vessels, &c. The 
same principles apply as in compound fracture. The same contin- 
gencies of age, temperament, and constitution, will influence the 
treatment. The question of amputation is first to be considered, 
and then the reduction. The after treatment would be that for a 
wound of the joint : careful closure of the wound, — prevention of 
inflammation by antiphlogistic means ; if possible preventing sup- 
puration, anchylosis, and tetanus. 



DISLOCATION OF THE JAW. 



Dislocation of the jaw may be caused by spasm of the pterygoid 



Fig. 9. 




muscles when yawnmg, 
or by a blow on the chin 
when the mouth is wide 
open. The condyles are 
pushed forwards, and rest 
in front of the base of the 
zygomatic process of the 
temporal bone. 

Symptoms. — The mouth 
gapes and cannot be shut, 
the glenoid cavity is va- 
cant, and there is a promi- 
nence felt beneath the zy- 
goma; the saliva trickles, 
articulation is prevented, 
and there is great pain. 



DISLOCATION OF THE RIBS. 53 

Treatment, — The patient should be seated on a low stool, and the 
surgeon standing in front, should press his thumbs, properly pro- 
tected, upon the last molar teeth, at the same time elevating the 
chin with the fingers. The condyles are thus extracted from their 
unnatural position, and returned to their socket by the normal action 
of the muscles, which produces an audible noise. In difficult cases, 
greater leverage may be obtained by using two forks or strong pieces 
of wood, connected by a string in such a way that it will elevate 
the chin, whilst the ends are pressed against the teeth in place of 
the thumb. When the resistance is great the efforts may be directed 
first to one side at a time. 

After reduction, the chin should be confined by a bandage for a 
week or ten days. 

DISLOCATION OF THE SPINE. 

This accident rarely happens unless connected with fracture ; 
although it has occasionally occurred in the cervical vertebrae. 

It may be produced by the muscular eifort of convulsion and 
mania, but more frequently is the result of violence ; for instance, 
falls from a height, crushing by wheels, hanging, &c. 

The chance of life is but small on account of injury done to the 
spinal marrow. The displacement is easily recognised by the de- 
formity, paralysis, &c. 

Dislocation of the atlas upon the dentata may occasion instant 
death, by the intrusion of its tooth-like process into the spinal 
marrow. Dislocations of the oblique processes simply may termi- 
nate with no other inconvenience than contortion of the neck and 
restricted motion of the head. The action of the diaphragm may 
be suspended by compression of the phrenic nerve. 

Dislocations of the bodies of vertebras of the neck and back, are 
almost necessarily accompanied by fracture. 

Treatment. — But little is to be expected. Great care is required 
in extension and coaptation. In the neck, danger is to be appre- 
hended from an attempt to reduce the deformity. Contusion of the 
muscles may produce a deformity which may resemble dislocation. 

Subluxation ox partial dislocation is more common; and it may 
terminate without permanent injury to the spinal marrow; provided 
the antiphlogistic system is pursued in all the details of rest, diet, 
purging, cups, &c. 

DISLOCATION OF THE RIBS. 

The vertebral extremity of the ribs can only bo dislocated by 
severe falls, or blows upon the back, on account of its ' double 
articulation, and its protection by the muscles of the back. The 
sternal extremity is sometimes loosened from the cartihige by violent 
bending of the body backwards; — great pain and difficulty oV breath- 



54 SURGERY. 

ing follows. Reduction can be effected by deep inspiration, slightly 
bending the body backwards and making some pressure on the 
projecting point. The subsequent treatment is the same as that for 
fracture of the rib. 

DISLOCATION OF THE CLAVICLE. 

The clavicle may be dislocated at either extremity, and is more 
rare than fracture. 

The sternal end may be dislocated upward, backward, and forward. 
(Fig. 10.) When dislocated upward, the sternal extremity approaches 
its fellow, and is much more elevated than the acromial extremity. 
When dislocated backward, which is more rare, there is a depression 
over the articulation, pain and stiffness in the neck, and difficulty 
of swallowing. When the direction is forward, which is the most 
frequent, it is produced by force applied at the opposite extremity. 
It is characterized by a projection over the spot, inclination of the 
head to the affected side, pain upon moving the arm, and the shoulder 
is brought near to the chest. 

The reduction is easy, — by means of extension and counter-exten- 
sion ; there is more difficulty in preventing a recurrence of the acci- 
dent. Dessault^s apparatus for fractured clavicle should be applied. 
But even with the greatest care, greater or less deformity commonly 
remains, which, however, does not interfere with the motions of the 
arm. 

The scapular end is generally dislocated upwards. Although 
sometimes it slides beneath the acromion. It is usually the result 
of a fall ; and is recognised by pain, impeded motion, depression of 
the shoulder, and the clavicle resting on top of the acromion occa- 
sions a projection. 

Reduction is effected by elevating the shoulder and depressing 
the corresponding end of the clavicle. Dessault^s bandage is then 
to be applied, and the part kept at rest. Some displacement usually 
remains, which does not prevent motion of the shoulder. 

DISLOCATION OF THE ARM. 

This is the most frequent dislocation, on account of the mobility 
of the shoulder joint, its constant exposure to injury, and the shal- 
lowness of the glenoid cavity, compared to the size of the head of 
the humerus. 

It may be displaced in three directions; viz., inwards, downwards, 
and backwards. In dislocation inwards, the elbow stands out from 
the body, and is inclined a little backward ; a protuberance is felt 
beneath the pectoralis major muscle, and there is frequently shorten- 
ing of the limb. 

In dislocation downwards, which is the most common displace- 
ment, the arm is lengthened, and there is great rigidity and 



DISLOCATION OF THE ARM. 



55 



immobility; the elbow 
stands out from the 
body ; there is a hol- 
low under the acro- 
mion process, and a 
prominence in the 
axilla. 

In dislocation back- 
ward, which is most 
rare, the elbow is in- 
clined inward and for- 
ward, the head of the 
bone forms a promi- 
nence beneath the 
spine of the scapula, 
and there is a hollow 
beneath the acromion, 
together with rigidity 
and immobility. 

Violence and con- 
traction of the mus- 
cles pectoralis major, 
latissimus dorsi, teres major, and deltoid, are the causes of disloca- 
tion of the arm. The immediate injury is a laceration of the capsule, 
contusion of the muscles, and effusion of blood, and often paraly- 
sis of the deltoid muscle from compression of the axillary nerve. 
Unless reduction is effected the parts become united by adhesions, — 
after which reduction cannot be produced without danger of lacerating 
the artery. 

Fig. 11. 




P 



A 



ISSS^^nIL. 


fS^f^l 


w --.I 


l^l^KT^l 


W 


- — --^ — . ^3w 



56 SURGERY. 

The reduction is managed in different ways. The ordinary plan 
is to place the patient on the bed, and then to place a spherical pad 
in the axilla. The surgeon makes counter-extension with his foot 
upon the pad, and extension with his hands. If this force is not 
sufficient, counter-extension may be made by passing a folded towel 
or sheet under the axilla, and securing the ends to the bed-post ; 
and extension by fastening a folded sheet or long towel to the wrist 
or elbow by a damp roller ; thus several assistants can make exten- 
sion at once. If this force is not sufficient, pulleys may be employed, 
taking care that the extension be made very gradually. 

The elbow has this advantage over the wrist, as a point of appli- 
cation of the extending band, — the elbow can be bent, and thus a 
greater rotatory movement of the head of the bone produced. The 
wrist is preferred by some, on account of there being no muscles 
compressed, whose contraction might interfere with the reduction. 

After reduction, which is recognised by cessation of pain, rotun- 
dity of the shoulder, and mobility of the limb, the arm should be 
kept in a sling, and not used for several days. Should paralysis of 
the deltoid continue, it may be relieved by stimulating lotions, blis- 
ters, moxas, &c. 

DISLOCATIONS A^^ THE ELBOW. 

When both radius and ulna are dislocated at the elbow, the fore- 
arm is bent nearly at a right angle, and is immoveable. The ole- 
cranon forms a prominence behind, and the articular extremity of 
the humerus, covered by the brachialis anticus muscle, forms a pro- 
tuberance in front. The coronoid process of the ulna is received 

Fig. 12. 




into the greater sigmoid cavity of the humerus, and tends to main- 
tain the bones in their unnatural situation. A lateral dislocation 
inwards may also occur, in which there is a great projection of the 
external condyle of the humerus, in addition to the symptoms of 
the first variety. 

When the ulna alone is dislocated backwards, the olecranon forms 
a marked projection posteriorly, the elbow is bent at right angles, 
and the forearm is pronated. 



DISLOCATION OF THE BONES OF THE HAND. 57 

Reduction of the above forms of dislocation is effected by making 
forcible extension of the forearm over the surgeon^ s knee, which is 
to be placed at the elbow, to make counter-extension. The forearm 
is to be bent while extension is produced. 

The radius is dislocated at its upper extremity, either forwards 
or backwards. Backwards is the most frequent displacement. The 
head of the bone forms a prominence behind, the arm is bent and 
the hand is prone. When displaced anteriorly, there is a distinct 
prominence in front, the arm is slightly bent, but cannot be com- 
pletely flexed, and there is some pronation. 

The reduction is eifected by making forcible extension and pro- 
nation at the same time, if the displacement be anteriorly ; if the 
displacement be posteriorly, supination is to be produced with exten- 
sion. In both, the head of the bone is to be pressed upon by the 
surgeon's thumb, in order to facilitate its sliding into its proper 
place. 

Dislocation at the elbow occurs but rarely, on account of the gin- 
glymoid character of the joint, and is generally accompanied by 
considerable laceration of the soft parts. Rest, cold applications, and 
a sling, are subsequently required, together with general antiphlo- 
gistic means. 

It is produced, most frequently, by force applied to the wrist, 
and when complicated with fracture of any of the processes, anchy- 
losis, gangrene, and other dangerous results may follow, especially 
if the reduction is delayed, and adhesions have formed. 

DISLOCATIONS AT THE WRIST. 

The radius and ulna may b* separated from the carpus, either 
anteriorly or posteriorly. When dislocated forwards^ there is a great 
projection in front, and the hand is bent backwards; when back- 
wards, the projection is behind, and the hand is flexed. 

It is produced by violent bending of the hand, and is accompanied 
by rupture of the ligaments and stretching of the tendons. The 
reduction is easily eff'ected by extension and pressure. Pain, swell- 
ing, and stiff'ness of the joint may follow, which are to be obviated 
by cold applications, rest, lotions, &c. ; if there should be a tendency 
to its reproduction, a light splint may be applied. 

If the radius alone is dislocated from the carpus, which is gene- 
rally anteriorly, the hand will be somewhat twisted, the radial side 
of it being thrown backward. The ulna may be dislocated back- 
wards upon the radius, rupturing the sacciform ligament, and pro- 
ducing a projection on the back of the wrist, by which it is easily 
recognised. It is readily reduced by pressure and extension. A 
splint and bandage may be necessary to prevent its recurrence. 

DISLOCATION OF THE BONES O V THE HAND. 

Displacement of the bones of the carj^us rarely occurs. C)eca- 



58 



SURGERY. 



sionally there is a dislocation of the phalanges of the fingers, but 
more frequently the dislocation backwards of the first phalanx of 
the thumb upon the metacarpal bone. 



Fig. 13. 




Reduction is effected by making extension in a curved line, by 
means of a narrow bandage or tape, firmly applied by a clove-hitch 
upon the phalangeal extremity. In some instances it may be neces- 
sary to divide the lateral ligament. 

DISLOCATIONS OF THE FEMUR, 

Dislocations of the thigh may occur in five directions : — 1st, up- 
wards and backwards, on the back of the ilium (Fig. 14) ; 2d, in- 

Fig. 14. Fig. 15. 





DISLOCATION OF THE FEMUR. 



59 



wards and downwards, into the foramen ovale (Fig. 15) ; 3d, back- 
wards, into the ischiatic notch (Fig. 16); 4th, upwards and for- 
wards, on the horizontal ramus of the pubes (Fig. 17) ; 5th, down- 
wards, under the tuberosity of the ischium. The first is the most 
the fifth is the most rare. 



common, 



Fig. 16. 



Fig. 17. 





In the most frequent displacements upivards and hachwards, the 
limb is shortened from an inch and a half to two inches and a half ; 
the toes rest on the opposite instep ; the knee is turned inwards and 
slightly bent ; the limb may be bent across the other, but cannot be 
moved outwards ; the trochanter is less prominent, and nearer the 
spine of the ilium ; and if the patient is thin, and there is no swell- 
ing, the head of the bone can be felt in its new position, and the 
rounded form of the hip is lost. It is to be distinguished from a 
fracture of the neck of the bone by the position of the foot and the 
rigidity of the limb. 

The reduction is the most difficult of all dislocations, and must 
be attempted as soon as possible after the disphicoment. If it is not 
produced, the head of the bone will adapt itself to its now position 



60 



SURGERY. 



by the formation of a new cavity, and the patient will gradually be 
able to walk^ the toes merely touching the ground. Bleeding, a 
warm bath, and tartar emetic must be administered, according to 
the patient^s constitution, in order to produce relaxation of the 
muscles. Counter-extension is to be made by a folded sheet or 
large towel placed in the perineum, the patient being in the recum- 
bent position, and secured to a ring or hook firmly fastened in the 
wall or floor. 

Extension is to be effected by securing a folded towel or sheet 
above the knee, by means of a damp roller ; this towel is to be 
acted upon gradually, by numerous assistants or by pulleys. The 

Fig. 18. 




extension is to be made gradually, in such a direction as to draw the 
thigh across the opposite one, a little above the knee. A third band 
or towel is to be passed around the pelvis, in order to fix it more 
firmly, the ends of which are to be tied on the sound side, which is 
to be given to an assistant. 

Dislocations hackwards in the sciatic notch are next in point of 
frequency. The head of the bone rests on the pyriformis muscle, 
between the sacro-sciatic ligaments and the upper part of the 
notch, a little above the level of the middle of the acetabulum. 
The shortening and inversion of the foot is not so great as in the 
first variety; the head of the bone can seldom be felt; the joint 
is extremely rigid, and motion of the limb almost impossible. In 
reducing this dislocation it is necessary that the head of the bone 
should first be brought out of the notch, before it can be restored to 
the acetabulum. 

Dislocations downwards and inwards are comparatively rare ; the 
limb is elongated nearly two inches ; the foot is advanced, though 
neither inverted or everted ; the thigh is abducted, and cannot be 
brought near to its fellow; the psoas and iliacus muscles form a ridge 
which can be seen or felt ; the trochanter is flattened and depressed, 
and the space between it and the anterior superior spinous process of 



DISLOCATIONS OP THE PATELLA- 61 

tlic ilium is much increased. To reduce this form, countcr-extcin- 
sion is to be made outwards by a band across the upper and inner 
part of the thigh : extension is to be made at the knee, which is 
gradually to be made to approximate its fellow. 

In dislocation upwarch and inv:ards, the head of the bone rests 
upon the horizontal portion of the pubes, under Poupart's ligament, 
where it forms a tumour. The limb is shortened an inch, and the 
foot is turned outward, and cannot be rotated. The reduction is 
effected by extension in the axis of the body. 

Reduction of the thigh is indicated by an audible noise when the 
head of the bone returns to its socket, by the natural length and 
direction of the limb, by the cessation of pain, and the free motion 
of the joint. 

After reduction there is sometimes a slight elongation of the limb, 
w^hich depends upon the swelling of the ligaments of the joint. The 
patient should be kept at rest, and may require antiphlogistic treat- 
ment; walking should not be attempted for several weeks. 

DISLOCATIONS OF THE KNEE. 

Dislocation at this joint is rare on account of its great strength. 
The displacement may be forwards, backwards, and laterally ; it is 
usually incomplete and readily reduced. 

The reduction is accomplished by extension of the leg and coap- 
tating the extremities of the bones. Subsequent inflammation and 
its results, anchylosis, suppuration, &c., are to be avoided by strict 
antiphlogistic means ; sustaining the weakness of the joint by splints 
or rollers, and removing the stiffness by lotions and frictions. 

The semilunar cartilages are sometimes displaced by twisting 
the joint, especially if an unusual relaxation of the ligaments should 
exist. The limb is immediately rendered stiff, and the pain is severe 
and sickening. Extreme flexion usually is sufficient to restore the 
parts to their position, although the pain and swelling remain for 
some time and require attention. 

DISLOCATIONS OF THE PATELLA. 

The patella may be dislocated anteriorly, posteriorly, and late- 
rally. Outwards is the most frequent displacement, and is charac- 
terized by the leg being stretched, a prominence externally formed 
by the patella, and a projection internally of the internal condyle. 

Reduction is effected by raising the leg and resting the patient's 
heel on the surgeon's shoulder, thus relaxing the muscles of the 
thigh ; at the same time the patella is to be forced into its place with 
the hand. This bone can only be displaced upward by a rupture 
of its tendon, and doivnivard by a laceration of the rectus muscle. 
It may be displaced by semi-rotation, one edge resting on the trochlea 

6 



62 SURGERY. 

of the femur, and the other forming a prominent ridge. Extreme 
flexion and coaptation will reduce it. 

DISLOCATION AT THE AXKLE. 

This accident is usually the result of severe force, and accom- 
panied by fracture of the malleoli. The displacement may be for- 
ward, backward, inward, and outward. 

Dislocation of the tibia inward is the most frequent, and owing 
to a fracture of the external malleolus, the foot is everted and the 
internal malleolus greatly projects. 

Reduction is effected by extension of the foot and flexion of the 
leg, so as to relax the gastrocnemius muscle. Dislocation of the 
tibia outward is occasioned by a fracture of the internal malleolus, 
and the deformity is the reverse of the last. Dislocation backwards 
may result from a fracture of the posterior extremity of the astra- 
galus, in which instance the foot is inverted as in varus ; this is 
more rare than dislocations forward, which result from fractures of 
the lower end of the fibula. There is danger of suppuration and 
gangrene, especially if connected with an external wound. Ampu- 
tation will often be the best resort, particularly when the constitu- 
tion of the patient is bad. 

DISLOCATION OF THE BONES OF THE FOOT. 

The astragalus is more " frequently dislocated than any bone of 
the tarsus ) and it may either be forward or backward. Unless re- 
duction can be effected, which is difficult, excision of the bone may 
be necessary, or amputation at the ankle. Dislocation of the other 
bones of the tarsus are usually compound injuries, and are to be 
treated upon general principles. 

INJURIES OF THE HEAD. 
THE SCALP. 

Contusion of the scalp may be very severe, on account of its 
being stretched over the resisting bony surface of the cranium, and 
being frequently connected with a lacerated wound. Owing to its 
vascularity, great swelling will occur from extravasation of serum or 
blood ; in many instances a fluctuating tumour being produced be- 
neath the integuments. The swelling which results being readily 
depressed in the middle, may give rise to the idea of a fracture, 
which is to be carefully diagnosticated. 

The treatment will require cold applications. In no instance is a 
coagulum of blood to be evacuated by incision or puncture ; but ab- 
sorption is to be promoted and depended upon, even if slow and 
tedious. It may be that the clot will produce inflammation and 
suppuration ; then a free incision should be made, and the exit of 



CONCUSSION. 63 

the pus favoured. Healthy granulation contracts the cavity , and 
the wound unites by the formation of a cicatrix. 

The constitutional treatment required may be different in the early 
stages from the latter^ being antiphlogistic or tonic^ as the symptoms 
demand. 

WOUNDS or THE SCALP. 

Simple incised wounds of the scalp give little trouble but that of 
hemorrhage, which is best arrested by a ligature or torsion ; a 
curved needle will be found more convenient to secure the vessels 
than the tenaculum. The edges are to be drawn together by adhe- 
sive straps^ in preference to stitches, on account of the danger of 
erysipelas. When a large portion of the scalp is lacerated, and 
hangs like a flap, it is not to be cut, even though it is attached by 
a very small process ; but, after being carefully cleaned, it is to be 
adjusted accurately, and retained in its place by proper bandaging. 
It thus protects the bone from exposure, and by granulation be- 
comes firmly united to the adjacent parts. Blindness may result 
from a wound upon the forehead injuring the supra-orbital nerve. 

CONCUSSION. 

By this is meant a jarring or shaking of the brain without any 
great lesion, though function is temporarily impaired ; inflammation 
is apt to follow. The force may be directly from a blow upon the 
head, or indirectly, from alighting upon the feet. The patient is 
stunned, is somewhat insensible, lies motionless, pale and cold. In- 
sensibility is not complete, for questions will be answered, and pain 
manifested by pinching; respiration is feeble, the pulse is rapid, 
small, and fluttering ; the pupils are insensible to light, sometimes 
contracted, and sometimes dilated ; nausea and vomiting often fol- 
low. After reaction, inflammatory symptoms commence, the pulse 
becomes full and hard, the skin hot and dry, the face flushed, the 
eyes bloodshot, great pain, especially in the head, restlessness and 
delirium. 

Treatment. — In the first stage, that of prostration, the chief care 
of the surgeon is to prevent some bystander from bleeding the pa- 
tient, in common with the vulgar notion. No active treatment 
should be resorted to until reaction has taken place. In the mean 
time the patient should be undressed and put to bed, and his limbs 
carefully examined ; the head should be shaved, wounds dressed, &c. 

Should the prostration continue, and danger impend from S3'n- 
cope, stimulation is to be resorted to in the most gradual and cautious 
manner ; warm frictions are to be employed, small quantities of tea, 
wine, and water are to be administered with care, lest thc}^ pass into 
the air-passages, and produce asphyxia. After reaction commences, 
stimulants are to be suspended, lest they increase subsequent iuflam- 



64 SURGERY. 

mation. By hurrying on reaction, life is often endangered, as by 
the too early abstraction of blood. So soon as inflammatory symp- 
toms fairly manifest themselves, we should endeavour to repress 
them by excluding all kinds of excitement, especially light and noise, 
and by the application of ice and evaporating lotions to the head, 
which should be elevated upon pillows. If great reaction occur, 
manifesting itself by delirium, convulsive movements, a full and 
active pulse, pain, &c., local and general bleeding, together with 
enemata and purgatives, are to be resorted to ; opium will also have 
a beneficial influence if administered judiciously, especially in con- 
nexion with calomel and tartar emetic. For some time after the 
violence of the inflammation has subsided, the brain remains weak 
and requires watchful care ; excitement, both physical and mental, is 
to be avoided, the diet regulated, and the head kept cool. The me- 
mory is often impaired, the conversation childish and incoherent, 
the eye wild and vacant in its expression, the demeanour either most 
timid and gentle, or entirely the reverse ; occasionally one or more 
of the special senses, such as hearing or smell, is lost ; such conse- 
quences may be temporary or permanent. The treatment most 
suitable is a mild mercurial course, long-continued counter-irritation, 
regulated diet, avoidance of all excitement and exposures to changes 
of weather, together with the use of the cold shower-bath. 

FRACTURES OF THE CRANIUM. 

These occur more frequently in adults than in children, on ac- 
count of the unyielding and brittle nature of their bones, whereas 
the bones of a child^s head are pliable, and yield to the force without 
fracture. Fractures of the cranium are classified, by the extent of 
injury, into simple fissure, stellated, depressed, and camerated frac- 
tures, fractures of the external or internal table, &c. The dangers 
attendant are various ; there may be concussion, compression, hemor- 
rhage, and inflammation of the brain and its membranes. 

A simple fissure is of but little importance, even should it be ex- 
tensive, and traverse a suture, which it often does. The fracture 
itself requires no treatment, unless accompanied by symptoms of 
concussion, compression, or inflammation. 

Fracture at the hase of the cranium is a very serious injury, and 
usually attended with laceration of the membranes, and internal 
kemorrhage. It is usually suspected, from the early appearance of 
symptoms of compression, the manner in which the injury was 
received, escape of blood from the ears, and sometimes from the 
nose and mouth. The latter symptom, although generally consi- 
dered a most dangerous one, may be the result of mere laceration 
of the lining membrane of the ear or the nose. The treatment re- 
quired will be that for inflammation or compression. 



COMPRESSION. 65 



A DEPRESSED FRACTUllE. 

This is to be carefully diagnosticated from a fracture of the exter- 
nal table alone, and from a depression in the middle of a tumour 
occasioned by the effusion of lymph. It is dangerous, from the com- 
plications of concussion, copaprcssion, extravasation of blood, and 
inflammation. The treatment consists in removing the cause of 
compression, and combating the effects of inflammation ; the former 
by the operation of trephining, and the latter by strict antiphlogistic 
means. 

COMPRESSION. 

Compression may be the result of extravasated blood, depression 
of the bone, or the formation of pus. The symptoms which cha- 
racterize it are slow, laborious, stertorous respiration ; a full, regular, 
slow pulse, and complete loss of consciousness and sensibility ; the 
muscles are relaxed and powerless, pupils dilated and insensible, the 
skin warm and moist, and the sphincters often relaxed. The patient 
may perish immediately from coma, or may rapidly recover from the 
removal of the cause of depression. 

Extravasation of blood may take place immediately upon the 
infliction of the injury, or not until reaction has followed ; concus- 
sion often being produced at the same time. The extravasation 
may be situated between the bone and the dura mater, which is the 
result of a wound of the meningeal artery. This may be the result 
either of a direct blow, or of a counter stroke. The symptoms 
gradually appear, and if urgent, the trephine should be used, and 
the blood, if fluid, escapes at once. If the symptoms be not severe, 
the clot may be absorbed, and the brain gradually recover from the 
compression, provided high inflammatory action is prevented. 

Blood may be effused within the membranes, or within the ven- 
tricles ; most frequently being the result of injury to the vessels of 
the pia mater. The clot effused within the membranes is usually 
larger, and will produce more dangerous symptoms than one external 
to them. The most dangerous consequences result from a clot at 
the base of the brain. 

Treatment — The objects are to prevent increased effusion and 
diminish subsequent inflammation, and the removal of the clot. 
The head should be elevated, cups and cold applications applied, 
with general bloodletting and purging. The action of the heart is 
to be diminished, in order to prevent the further extravasation of 
blood.- The removal of the clot is accomplished by trephining, and 
opening the membranes. If, however, the clot is at the base of the 
cranium, or it is uncertain where it may be, the membranes are not 
to be opened, for the chances of inflammation would bo much in- 



66 SURGERY. 

creased by the operation , and the cause of compression not certainly 
removed. 

Compression 7'esulting from the formation of pus, does not exhibit 
the ordinary symptoms rapidly, as in the case by the escape of 
blood; nor do the symptoms subside so readily ; because pus is not 
so amenable to absorption as blood. It cannot be discharged but 
by the exfoliation of the bone, which is a tedious process. The 
symptoms denoting the formation of this dangerous abscess, affect 
the system as well as the part; and the patient would manifest the 
same restlessness, rigor, and fever, which attend the formation of 
pus in other parts of the body. 

TREPHINING. 

The scalp is first to be cleanly shaved ; and if a'^ wound already 
exist, the cranium may be exposed simply by enlarging it ; but if 
no previous wound exist, an incision is to be made, of a crucial, 
triangular, or semicircular shape, — the latter being most preferred. 
The pericranium is then to be detached by a scraper, unless the 
trephine have an additional means for removing it. That portion of 
the cranium should be selected which is sufficiently near the injured 
parts to allow of elevation of the fragments, by the introduction of 
an elevator, and at the same time to be sufficiently firm to bear the 
pressure of the trephine. The sinuses of the dura mater, the occi- 
pital cross, and the course of the middle artery of the dura 'mater, 
are to be avoided. The centre-pin of the trephine is to be withdrawn 
after a groove is made sufficiently deep for the play of the teeth of 
the instrument ; and great care is to be taken, lest the trephine saw 
through the bone unequally, owing to the want of parallelism of the 
two tables of the skull. The progress of the operation is to be 
cautiously watched, and the depth of the groove made by the 
trephine, ascertained by a toothpick or a small probe. The button- 
like portion of bone frequently comes away in the trephine ; if not, 
it is to be removed by a forceps or elevator ; the rough edges (should 
any exist) of the internal table, are to be taken away by an instru- 
ment called a lenticular. Through the opening thus made, the 
elevator may be introduced, or the extravasated blood may escape. 
The opening is subsequently filled up by a dense membrane, formed 
by the pericranium and dura mater. The edge of the opening is 
somewhat altered by absorption, and some deposit of bone. In 
some instances of compound fracture of the skull, a prominent angle 
may be sawed off with Hey's saw, and thus an opening be formed 
sufficiently large for the admission of the elevator, or the exit of the 
bloody clot. 



DISEASES OF THE FACE^ NOSE^ AND MOUTH. 67 



INJURIES AND DISEASES OF THE FACE, NOSE, AND MOUTH. 

Wounds of the face are usually attended with considerable hemor- 
rhage, which sometimes requires the tying of an artery. Care is 
required to approximate the edges, in order to prevent deformity, 
and an ugly cicatrix. When the supra-orbital nerve is injured, 
vision is impaired ; when the portio dura nerve is cut, paralysis of 
the muscles upon one side of the face results. 

WOUNDS OF THE EXTERNAL EAR. 

Do not affect the hearing; but when the cartilage is cut, a split 
will remain, unless the integuments are carefully united. 

WOUNDS OF THE EYEBALL. 

Produced by great violence, such as gun-shot wounds, of course 
destroy the sight, and are often followed by a fungous growth, 
which requires removal and the substitution of a glass eye. 

WOUNDS OF THE TONGUE. 

Bleed very copiously, and there is some difficulty in arresting 
hemorrhage. This is to be effected by a ligature and styptics ; and, 
if necessary, by the actual cautery. Sutures are necessary to ap- 
proximate the edges of the wound. 

SALIVARY FISTULA. 

This results from a wound or ulcer of Steno's duct, by which the 
discharge of the parotid gland opens externally on the cheek, occa- 
sioning great inconvenience and deformity, and interfering with the 
processes of mastication and digestion. A cure is to be effected by 
making an opening through the mucou-s membrane of the cheek, 
that the saliva may enter the mouth, and by closing the fistulous 
orifice. The edges of this orifice will require cau-stic, or paring with 
a sharp knife, or the actual cautery, to make them unite, and the 
internal orifice is to be kept open by a tent. 

EPISTAXIS. 

This implies hemorrhage from the nostril, produced by injury, 
plethora, or diseased state of the blood and mucous membranes. 
The treatment will, in a great measure, depend upon the cause. 
The arrest of hemorrhage by external applications, is only to be 
made under certain circumstances; it will be effected by an upright 
position, cold applied to the head and back, astringents thrown up 
the nostrils, and compression by lint. In some instances, the lint 
is to be introduced through the posterior nares, by means of Bel- 
loque's canula, or by a flexible catheter and a piece of string, where 



bb SURGERY. 

it must be allowed to remain for several days ; in many instances, 
constitutional treatment is necessary. 

FOREIGN BODIES IN THE NOSTRIL. 

Peas, beads, and such like substances are often inserted by thought- 
less children : and by unwise efforts at removal, they are more deeply 
lodged in the cavity. The surgeon is to inject a stream of warm 
water into the nose, which will wash away any coagula of blood, and 
loosen the foreign body ; its position is to be discovered by a probe, 
when it can be extricated by a scooped end of a director or forceps. 
A pinch of snuff will sometimes dislodge it. 

POLYPUS OF THE NOSE. 

There are different varieties of polypi : the most common is a 
gelatinous, pyriform mass, attached to the mucous membrane of the 
turbinated bones. The patient has a sensation of a cold in the 
head, which is much increased in damp weather. It interferes with 
respiration, and frequently alters the tone of the voice. The sense 
of smell is also impaired, and deafness may be produced, should it 
occupy the orifice of the Eustachian tube. It may be removed by 
twisting it off by the forceps ; and the hemorrhage is to be arrested 
by astringent injections and lint. A dense fihrous polypus is best 
removed by a ligature or wire, applied by means of a double canula, 
for the purpose of strangulation. Malignant polypi may be regarded 
as incurable. 

LIPOMA or THE NOSE. 

Is a hypertrophied condition of the skin and fat of the apex, and 
alee of the nose ) seldom occurring but in aged free-livers. When 
the growth is large, it is to be removed by the knife. 



Is an obstinate, profuse and foetid discharge from the mucous 
membrane of the nose, with disease of the bones beneath. The 
disease often extends to the frontal sinus and antrum. In adults, 
it is often dependent upon syphilis, or the abuse of mercury ; in 
children, upon scrofula. 

The treatment will in a great measure be constitutional, although 
benefit and comfort will be derived from the use of astringents and 
chlorine washes, and promoting the free discharge of the matter. 

ABSCESS OF THE ANTRUM. 

May result from a blow, or the irritation of a decayed tooth. It 
is attended with permanent, deep-seated aching of the cheek, the 
pain often becoming intense, together with rigors and fever. The 
cavity bursts, either internally or externally, which gives great re- 



WOUNDS AND AFFECTIONS OF THE THROAT. 69 

lief. The earlier that leeches and emollient poultices are applied, 
the better ; but, after the cavity has become filled with matter, there 
is necessity for immediate puncture just over the third molar tooth ; 
or, a tooth must be extracted, and a trocar pushed through the 
socket. The discharge of pus can be facilitated by syringing with 
warm water. 

EPULIS. 

Is a solid tumour of the gum, of a non-inflammatory character. 
It commences in the form of a seed-like excrescence upon the gums, 
between the interstices of the teeth. Being without sensibility, it 
may occasion but little inconvenience, except by its size. As it grows, 
it loses its dense fibrous structure, and may become fungous ; some- 
times it becomes malignant. 

Treatment. — Nothing will suffice but complete extirpation of the 
adjacent portion of the gum and alveolar process. Several perfectly 
sound teeth may have to be drawn, in order to apply a fine saw, or 
bone-pliers. The hemorrhage is to be arrested by muriated tinc- 
of iron, and pressure by lint. 

P ARULIS. 

Is a gum-boil ) occasioned usually by a decayed tooth, or a stump, 
or a tooth whose nervous pulp had been destroyed previous to plug- 
ging. The swelling is slow at first, though the pain is intense while 
the pus is forming. Unless the tooth is extracted, an opening will 
be formed through the alveolar process and gum, for the discharge 
of the matter, which may remain fistulous. 

The treatment will consist of leeches and fomentations, and the 
speedy evacuation of the abscess, either by the abstraction of a tooth, 
or by puncture. 

K ANUL A. 

Is a sac formed beneath the tongue, by an expansion of Wharton^ s 
duct, either from disease or obstruction. Inconvenience is felt in 
mastication, deglutition, and articulation. 

The treatment consists of dilatation of the duct, or making an 
artificial opening. It is necessary to keep the orifice distended by a 
tent or loop of wire, until the cyst contracts to its normal size; 
otherwise it will be refilled. 



WOUNDS AND AFFECTIONS OF THE THROAT. 

INFLAMMATION OF THE TONSILS. 

This is characterized by the rapid swelling of the part, groat pniu 
in deglutition, and fever. It is to be treated by blooding, loocho?!, 



70 SURGERY. 

purging, and gargles. An incision made with a bistoury will un- 
load the vessels, and give exit to any pus which may have been 
formed. 

Chronic enlargement of the tonsil may result from inflammation, 
especially in scrofulous persons ; deglutition is impeded, the voice 
is rendered hoarse, respiration is noisy and laborious, and there may 
be deafness, from the obstruction of the Eustachian tube. 

The treatment should consist of the internal and external use of 
iodine, astringent gargles, and the application of nitrate of silver. 
If these means fail, it should be removed by the knife, or with an 
instrument constructed for the purpose, such as Physick's or Fahne- 
stock^s. 

ELONGATED UVULA. 

This may be removed simply by a forceps and scissors. 

STRICTURE OF THE (ESOPHAGUS. 

The oesophagus may have a permanent or spasmodic stricture. 

Spasmodic stricture comes on suddenly, generally at meals, and is 
attended with pain, and a choking sensation. It depends on a weak- 
ened or hysterical state of the system, or neuralgia. Tonics, anti- 
spasmodics, and alteratives are the means of cure, with proper 
attention to diet, and care to avoid swallowing food that is hot or 
imperfectly masticated. 

Permanent stricture is a narrowing produced by inflammation of 
the mucous and cellular coats, which forms a firm ring generally 
opposite to the cricoid cartilage. It is most frequent in females, 
and has these symptoms : difiiculty of swallowing, which gradually 
increases, and is never absent ; pain in the chest and neck. It is a 
serious complaint, and may be followed by ulceration, salivation, 
vomiting of purulent matter, and death from starvation or irrita- 
tion. 

The treatment should consist of a mild course of mercury, com- 
bined with some anodyne, a seton between the shoulders, and the 
passage of a bougie, together with a weak solution of nitrate of sil- 
ver applied to the surface. 

FOREIGN BODIES IN THE CESOPHAGUS 

Produce a sense of choking and suffocation, and may prove fatal. 

Treatment. — The patient should be seated in a chair, with his 
head thrown back, and his mouth wide open; the surgeon should 
then introduce his finger, regardless of the attempts to vomit, ascer- 
tain the position of the substance, and if possible remove it by the 
finger, or by the assistance of curved forceps. A small sharp body, 
such as a fish-bone, may be got rid of by swallowing a large mouth- 



WOUNDS AND AFFECTIONS OF THE NECK. 71 

ful of bread; a large soft mass, such as a piece of meat, may Ijc 
pushed down into the stomach with a probang; a rough and angular 
body, such as a piece of bone or glass, should be brought up, if 
possible, by long and curved forceps, or with a piece of whalebone, 
armed with a fiat, blunt hook, or with a skein of thread, so as to 
form a number of loops. If the stomach is full, it should be 
emptied by an emetic, with the hope that the foreign body may be 
ejected with the food. It may be necessary to rejjort to the opera- 
tion of oesophagotomy, which should be performed by making an 
incision as nearly opposite the foreign body as possible, through the 
skin, platysma and fascia, and between the sterno-mastoid muscle 
and trachea. Care must be taken to avoid the carotid and thyroid 
arteries, and the recurrent nerve. A small opening should be made 
in the oesophagus, by cutting it upon a silver catheter, which should 
be passed down the throat, and made to project into the wound ; the 
opening should be dilated, so as to prevent hemorrhage. 

FOREIGN BODIES IN THE LARYNX AND TRACHEA. 

Food may get into the rima glottidis, whilst a person is laughing 
and talking at a meal; and unless immediate relief is afforded, 
death will result. The surgeon may sometimes be enabled to re- 
move it with his finger ; but if not, the larynx or trachea should be 
opened, and a probe introduced through the wound, so as to push 
the foreign substance up into the mouth. A foreign body may be 
impacted in the ventricle of the larynx, or be loose in the trachea, 
producing spasmodic cough, difficulty of breathing, and pain; a 
small body may even pass into the bronchial tube, generally the 
right one. Laryngotomy, or tracheotomy, may be necessary. The 
larynx is opened by a longitudinal incision through the middle 
crico-thyroid ligament. The trachea is opened in the median line 
through the skin, fat, and fascia, at the lower portion of the neck. 
After the tracheal rings are made bare, the patient is directed to 
swallow; and while the windpipe is thus rendered tense and elon- 
gated, the scalpel is made to penetrate the lower part of the wound, 
with its back towards the sternum, and the rings are to be divided 
by cutting upwards. Care should be taken, in this operation, to 
avoid opening large veins, or any part of the thyroid gland. This 
operation is sometimes necessary for dyspnoea, when a conical curved 
tube should be introduced for the patient to breathe through. 

WOUNDS AND AFFECTIONS OF THE NECK. 

■WOUNDSOrTHENECK. 

Are extremely dangerous, on account of the important parts in- 
jured, and are usually the resuUs of attempted suicide. 

The treatment consists in arresting hemorrhage, obviating difli- 



72 SURGERY, 

culty of breathing, and preventing inflammation. The arteries must 
be rapidly yet carefully tied, and the hemorrhage of the large veins 
restrained by pressure. If the larynx or trachea should be wounded, 
subsequent inconvenience may result from the introduction of cold 
air, clots of bloody &c. ; if the pharynx or oesophagus is wounded, 
the use of a tube becomes necessary, in order to convey nourish- 
ment to the stomach. This tube must be introduced through the 
mouth, and not through the wound, as often as it may be necessary 
to supply the patient with food. The edges of the wound should be 
carefully drawn together, and dressed in the most simple manner, 
and should be protected from unfavourable atmospheric influences 
by a covering of loose gauze, or of woollen texture thrown lightly 
over the neck. The patient should be carefully watched, to prevent 
a recurrence of the injury. A fistulous opening sometimes remains 
in the trachea or larynx, which is extremely difficult to heal. 

BRONCHOCELE, OUGOITRE. 

Is a swelling of the thyroid gland, depending, for the most part, 
upon hypertrophy, although a cyst may be formed, or calcareous 
matter deposited. In certain localities, it is 
■^^S- 19- an endemic disorder, and often associated 

|\/ j/..:^, ..---v^ with cretinism. It occurs most frequently 

in females after the age of puberty. It 
grows gradually, and without pain, occa- 
sioning inconvenience merely by its defor- 
f4'' \ mity and bulk. Respiration is sometimes 
if ^1 afi*ected, and the venous blood being pre- 
^ ' I vented from returning from the head pro- 
%5' duces cerebral disorder. The cause of the 
disease is obscure, but probably connected 
with climate. 

The treatment will consist in the use of 
iodine, internally and externally, with at- 
tention to the general health ; or it may be 
necessary, under the threatening of sufi'ocation, to perform an opera- 
tion. The removal of the gland is extremely dangerous, on account 
of hemorrhage, and does not always produce a cure. 

TORTICOLLIS, OR WRYNECK. 

This is a distortion of the neck to one side, generally the result 
of spasm of the sterno-cleido-mastoid muscle, or by a paralysis of 
the muscle of the opposite side. It may also result from tumours, 
caries of the spine, and cicatrices, especially those from burns. 

The treatment will vary with the causes producing it. If it re- 
sult from spasm, purgatives, leeches and fomentations should be 
used ; if from paralysis of the opposite side, general tonic treatment 




INJURIES AND AFFECTIONS OF THE CHEST. 73 

and stimulating friction will be useful. If the contraction be per- 
manent, the muscle must be divided. 

INJURIES AND SURGICAL AFFECTIONS OF THE CHEST. 

Wounds of the chest may be inflicted by a sharp instrument, a 
fractured rib, or a bullet. Danger results from hemorrhage, and 
subsequent inflammation from air, or clot of blood in the pleura. 
The intercostal may be the source of the bleeding, and it is some- 
times difficult to arrest it by the ordinary means. A curved needle, 
armed with a ligature, is the best means of securing the vessel, 
when deeply concealed in the intercostal groove. The entrance of air 
into the chest (pneumothorax) through the wound is to be pre- 
vented as much as possible by the early and accurate closure of 
the wound ; otherwise there may be compression of the lung. The 
suppuration of the wound may lead to inflammation and suppura- 
tion of the pleura. This collection of pus in the chest is called 
empyema. 

When the lung is wounded, there is still greater danger from 
hemorrhage, inflammation, and the air. It is attended with great 
prostration, difficult breathing, anxiety of countenance, and expecto- 
ration of blood. The danger of bleeding results not only from the 
direct loss, but from its collecting in the pleura (hasmatothorax), 
and its filling up the bronchial tubes and trachea. The inflammation 
may subsequently destroy the lung, and the life of the patient also 
by hectic. The air may also more readily enter the cavity of the 
chest, and not being readily discharged through the external wound, 
may infiltrate into the subcutaneous cellular tissue. 

The hemorrhage is to be controlled by venesection, rest, and 
other antiphlogistic means. A careful examination of the wound 
should be made, in order that no foreign matters remain; the patient 
should lie on the wounded side, so as to favour the discharge of 
blood or pus, and it may also be necessary to prevent a closure of 
the wound. Emphysema may be overcome by compression, or an 
incision. 

PARACENTESIS THORACIS. 

Puncture of the thorax, may be required for accumulated air, 
blood, or pus. The opening is most frequently for empyema. The 
point selected is usually between the sixth and seventh ribs, half 
way between the spine and sternum. If made too low, the dia- 
phragm may be wounded ; if too high, the fluid will not so readily 
escape. The opening should be closed with care, to avoid the en- 
trance of air. 

7 



74 SURGERY. 



WOUNDS OF THE ABDOMEN. 

Wounds of the ahdomen are extremely dangerous, on account of 
the important viscera contained within, and the liability to perito- 
nitis. A simple wound of the parietes must be closed by suture if 
it is extensive, care being taken not to include a portion of the in- 
testine. When complicated with a wound of the liver, fatal hemor- 
rhage must almost necessarily result, on account of the great vascu- 
larity of the organ. A patient may survive a small wound, which 
will be succeeded by great prostration, pain in the liver, yellowness 
of the skin and urine, and a bilious discharge of the wound. 

The wounds of the gall bladder ^ and spleen j and urinary bladder^ 
if communicating with the peritoneum, are almost always fatal. 
Wounds of the hidney are also exceedingly dangerous from hemor- 
rhage, violent inflammation, and suppuration, with excessive vomit- 
ing. Venesection, laxatives, warm bath, avoidance of drinks, with 
light dressings of the wound, are the proper measures for treatment. 

PROTRUSION OF THE BOWEL. 

When a portion of the intestine protrudes through a parietal 
wound of the abdomen, it is to be returned with great gentleness 
and accuracy, so as to avoid inflammation and obscure strangulation. 
The edges of the wound are to be carefully approximated, by suture 
if necessary, and by moderate bandaging such pressure is to be 
made as to prevent reprotrusion. 

WOUND or THE BOWEL. 

A wound of the bowel may be suspected from the passage of 
blood with the stools, the escape of fseces through the wound, ex- 
cruciating pain over the whole belly, and a great tendency to col- 
lapse. 

Extravasation into the cavity of the peritoneum does not take 
place from a small wound, owing to the protrusion of the mucous 
coat through the muscular, and the constant and equable pressure 
of all the abdominal viscera ; lymph is also rapidly efl'used, and the 
contiguous edges are thus united. If, therefore, the protruded part 
be found to have sustained a mere puncture, it is to be returned as 
if entire. A small incision may be closed by the glover's suture; 
the ends are cut short, and the exudation of lymph envelopes the 
thread, which in time finds its way into the cavity of the bowel; and 
is thence discharged. 

If the portion of bowel be bruised and lacerated to such an extent 
as to render adhesion impossible, and gangrene probable, the wounded 
part must be retained at the surface, and the peritoneal coat united 
with the integuments at one or more points ; the faeces are thus dis- 



ARTinOIAL ANUS. 75 

charged through the external wound, and an artifical anus is thus 
established. 

WOUNDS OF THE STOMACH. 

Are recognised by vomiting of blood, and the nature of the mat- 
ters which may escape from the wound. They are much more dan- 
gerous than those of the bowel. The edges of the stomach and the 
edges of the external wound are to be stitched together by the con- 
tinuous suture. The subsequent treatment should '^consist of perfect 
rest, and the prevention of inflammation; venesection and leeches, 
and large doses of opium, will probably be necessary ; nothing but 
thin arrow-root, or mucilage, should be given as a diet, and it may 
be necessary to administer this by the rectum : purgatives should 
be studiously avoided. 

ARTIFICIAL ANUS. 

This is an unnatural opening of the intestine, through which 
fseces are discharged. It may be the result of a wound, or slough- 
ing consequent on strangulated hernia. The orifices of the upper 
and lower portion of the intestine are united with the abdominal 
wall. The lower portion of the bowel becomes contracted, and re- 
ceives but little faeces. The integuments around the artificial open- 
ing form a funnel-shaped cavity, the edges of which are red, 
everted, and excoriated. The consequences of the affection may be 
inanition by the escape of chyle, especially if the upper portion of 
the small intestine be engaged ; a patient is liable to hernia, colic, 
besides the disgusting annoyance of the constant escape of faeces and 
flatus. 

The treatment will consist of regulating the bowels by diet and 
medicine, and by supporting the orifice by a compress or truss, 
which will retard the escape of the discharge, and promote the con- 
traction and cicatrization of the funnel-shaped cavity. It may be 
necessary to perform Physick^s operation : this consists of intro- 
ducing a ligature by means of a curved needle into the orifice of the 
upper intestine, and bringing it out through the orifice of the lower, 
which ligature is then to be secured with a slip-knot. The object 
of this ligature is to produce adhesion between the peritoneal sur- 
faces of the upper and lower intestine : this will require several 
weeks ; afterwards, an opening is to be formed through this adhe- 
sion by means of a bistoury, through which the frecos will pass from 
the upper to the lower intestine, the external orifice being firmly 
compressed with a truss. Dupuytren operated by means of a for- 
ceps, one blade of which was inserted into the orifice of each intes- 
tine, and the pressure regulated by a screw at the handle. The 
effect of the pressure of the two blades of the forceps, is first to 



76 SURGERY, 

produce adhesion between the sides of the two intestines, and by 
still greater pressure, to form an opening between them by ulcera- 
tion. 

HERNIA. 

Hernia signifies a protrusion, but the term is usually limited to 
the protrusion of the abdominal viscera. The predisposing cause is 
a weakness of the parietes of the abdomen at the natural openings. 
This weakness may be increased by injury, disease, or pregnancy, 
and there may also exist a congenital deficiency. 

The exciting causes are muscular exertion, jumping, straining, 
playing on wind instruments, coughing, vomiting, lifting weights, 
tight clothes, parturition, straining at stool, &e. Hernia is divided, 
according to the site of the protrusion, into inguinal, ventro-ingid- 
nalj umbilical, ventral, phrenic, perineal, vaginal, pudendal, thy- 
roideal, and ischiatic. The condition of hernia is also a ground of 
division into reducible, irreducible, and strangulated ; and if the 
contents of the sac be intestine, it is called enterocele, if it contains 
omentum, it is called epiplocele. The sac is formed of peritoneum, 
and the difi*erent parts are called mouth, neck, and fundus. 

REDUCIBLE HERNIA. 

Symptoms. — A painful swelling suddenly forms at some part of 
the abdominal parietes, which is compressible and soft ; it can be 
made to disappear by pressure in the proper direction, and it 
often disappears spontaneously. An enterocele is smooth, elastic, and 
globular, retires suddenly, and with a gurgling noise. An epiplo- 
cele is more irregular in its form, has a doughy feel, and retires 
slowly without noise. 

Treatment. — The treatment consists of reduction and retention. 
Reduction is effected by a manipulation termed taxis, the patient 
being placed in a recumbent position, and the muscles of the abdomen 
relaxed ; gentle and steady pressure is made by the hand in the 
direction of the descent. Retention is effected by continued and 
suitable pressure over the site of the protrusion, by means of a truss. 
The points of a good truss are, a well-made elastic spring and a 
pad, that can be accurately fitted. The spring is to be applied two 
inches below the crista of the ilium, and not above it, as is fre- 
quently done. Care must be taken to prevent excoriation, and also 
that every portion of intestine or omentum is removed from the sac 
previous to its application. By constant and careful use of a truss, 
a radical cure may be effected in a child, but rarely, if ever, in an 
adult. 



STRANGULATED HERNIA. 77 



IRREDUCIBLE HERNIA. 

When the contents of the sac cannot be restored to the abdomen, 
the hernia is called irreducible. It may arise from adhesions be- 
tween the sac and the intestine contained, or from membranous 
bands stretching across the sac; from great enlargement of the 
omentum or intestine, or contraction of the cavity of the abdomen. 
The patient usually suffers from flatulence, indigestion, and consti- 
pation, owing to the peristaltic movements of the bowels being par- 
tially interrupted. 

The treatment consists in carefully regulating the bowels, avoid- 
ing any great exertions, and the wearing of a bag truss to support 
the tumour, and prevent further protrusion. 



STRANGULATED HERNIA. 

This is an incarceration of the contents of the sac, with inflamma- 
tion and an interruption to the passage of fseces and the circulation 
in the part. The inflammation is caused by the constriction, which 
may be the result of spasm, or sudden enlargement of the intestine 
by fseces or gas. 

The symptoms are flatulence, constipation, pain in the part and 
abdomen, nausea and vomiting ; sometimes the matter is stercora- 
ceous. The countenance is pale and anxious, the skin cold and 
clammy, and the pulse, which was at first full, now becomes rapid 
and indistinct ; gangrene has taken place, the pain subsides in the 
tumour, which feels doughy and crepitant upon being handled. The 
vomiting may cease, and the patient will appear more comfortable, 
although he is actually sinking. It may be that the integuments 
and coverings of the intestine may inflame and slough with the in- 
testine ; and, after a copious feculent discharge, the patient may 
recover by artificial anus. 

When the tumour is small and recent, and the constriction tight, 
a few hours may produce death, if no relief is afforded ; when the 
hernia is old and large, days may elapse. 

Many of these symptoms may exist in other diseases, as in colic 
or ileus, but inquiry or examination should always be made as to 
hernia. 

Treatment. — The great object is to relieve the strangulation. In 
the first place taxis should be resorted to, and an effort made tu 
reduce the contents of the sac. In order to facilitate this object, 
bleeding, warm bath, purgatives, euemata, opium, and cold applica- 
tions to the tumour will be found of use. A tobacco injection, made 
with 5J to Oj of water, may be of use, but requires groat caution in 
its use, on account of its prostrating eftect. These remedies may so 



78 SURGERY. 

relax the system that the reduction can be effected ; at any rate they 
will diminish the inflammation if judiciously used. If not successful, 
the knife must be used. 

INGUINAL HERNIA. 

Bubonocele is a common name for this variety of hernia, which 
consists of a tumour in the groin, made by a descent of the gut or 
omentum through what are called the rings of the abdomen. These 
are the weak spots at which the protrusion takes place. 

Before studying the operation for strangulated inguinal hernia, 
it will be proper to examine the anatomy of the parts in their 
natural condition, and then the varieties of the disease. 

For anatomy of inguinal hernia refer to Anatomy , page 77. 

Oblique, or indirect inguinal hernia, occurs thus: — The intestine, 
or omentum, first pressing against the parietal peritoneum, distends it 
and forms it into a sac; this sac, containing the intestine, then presses 
against the fascia transversalis at that portion where it is thin, and 
passes from the abdomen to the cord, which spot is called the in- 
ternal abdominal ring, although it is not a hole. The sac, covered 
by the fascia transversalis, which is now thickened by pressure, 
then descends the inguinal canal, behind the transversalis and in- 
ternal oblique muscles, and when it reaches the external ring it 
is covered by the cremaster, which may be considered as a con- 
tinuation of these muscles ] thus covered, it escapes at the external 
ring, and there receives an investment from the intercolumnar super- 
ficial fascia and the skin. We thus see that the intestine is covered 
by a representation of all the structures forming the parietes of the 
abdomen, with the exception of the external oblique muscle. 

Direct, or ventro-inguinal hernia, is a protrusion at the external 
abdominal ring, having its coverings formed in very much the same 
manner as the last, but instead of the cremaster muscle forming a 
covering, it is covered by the expanded tendon of the internal ob- 
lique and transversalis muscles. Sometimes this tendon is split, 
and there is no covering representing this portion of the parietes of 
the abdomen. The tumour in this variety is nearer the symphysis 
pubis, and is on the inner side of the epigastric artery, whereas, in 
the indirect variety, the tumour is on the outer side of the epigastric 
artery. 

Concealed inguinal hernial^ a term applied to a protrusion which 
has been detained in the inguinal canal. 

The operation for relieviug the stricture in an indirect inguinal 
hernia is to be performed by placing the patient upon the edge of a 
table, with each foot resting upon a chair ; the surgeon sits before 
him, and makes an incision extending from the upper part of the 
tumour nearly to its base. The skin having been divided, the super- 
ficial fascia must next be divided. This will be found to exist in the 



INGUINAL HERNIA. 



79 



form of laminae, the most inferior of which is the thickest ; having 
been, in the natural condition of the parts, that portion of the fascia 
which fills up the space between the columns of the external ring, 

Fig. 20. 




and which is sometimes called the intercolumnar fascia. After this 
division the cremaster muscle will be exposed, altered from its na- 
tural appearance ; the fibres being stretched and separated from 
each other, and being more pallid than natural. Having divided 
these fibres, the next covering will be the fascia transversalis, which 
is continued from the abdomen upon the cord; this being done the 
hernial sac is then exposed. 

The sac being formed of peritoneum, has been mistaken by some 
for the intestine, from which it is to be distinguished by not having 
a flexure, or crease, which the intestine always has. The sac is to 
be opened carefully, pinching up a part and rubbing it between the 
fingers, in order that no portion of intestine may be included ] a 
small opening is to be made, and into this a director may be intro- 
duced and the sac divided freely. 

Bloody serum will escape freely, and the contents of the sac be 
thus exposed; the convolution, or knuckle of intestine will vary in 
its colour, according to the period and intensity of its strangulation, 
between a light red and a deep chocolate colour; very often the in- 
testine will exhibit patches upon its surface when the inflammation 
has been intense. The finger is then to be introduced to examine 
the point of stricture ; if none should exist, an attempt at reduction 
should be made, if the intestine be in a proper condition. The 
stricture having been detected, a probe-pointed bistoury, with a cut- 
ting edge only near the extremity, is introduced flat upon the finger, 
and a slight cut made directly upwards to the extent of one or two 
lines. The only danger to be approhendod is the wounding of the 



80 



SURGERY. 



epigastric artery, and this is avoided by making a vertical, instead 
of a lateral incision. The sac may be strictured by the external or 
internal ring, or in the canal by the lower edge of the transversalis 
muscle. 

Fig. 21. 




The stricture being relieved, the gut is to be returned, the edges 
of the wound are to be carefully approximated, and a compress 
applied to support the part, and prevent accidental reprotrusion. 
A mild laxative may be given in a few hours if there is no peristaltic 
motion of the bowels ; sometimes the bowel seems to have been pa- 
ralysed by the compression, and its peristaltic action is not recovered 
for several hours. Danger results then from the accumulation of 
medicines, food, &c., and life may be lost by inflammation of the 
bowel subsequent to its reduction. The antiphlogistic treatment 
will be most serviceable. After cicatrization a truss must be worn 
to prevent a return of the protrusion, though occasionally the opera- 
tion produces a radical cure. Such is the course of an ordinary 
case ; but*it may be found upon opening the sac, that the hernia is 
irreducible, owing to the intestine adhering to the sac ; the stricture 
is to be relieved, and the wound dressed, and no attempt made to 
restore the intestine, unless the adhesion be recent or slight. 

Should the intestine be extensively mortified it is not to be re- 
turned, the only chance of life being through the establishment of 
an artificial anus ; but if mortified only in a few spots, the spots are 
to be included with a fine ligature, and the intestine returned; the 
ligature finds its way into the interior of the gut, and is discharged 
with the feeces. 

In case there should be a gangrenous condition of the omentum, 
the gangrenous part should be cut ofi\, and the vessels secured by 
fine ligatures ; the remainder may then be returned to the abdomen, 
or be allowed to remain impacted in the outlet, and thus prevent 
future tendency to protrusion. 

Some have successfully divided the stricture exteriorly to the sac, 
the sac being reduced with the hernia. The objection to this opera- 



FEMORAL HERNIA. 



81 



tion is the danger of there being a stricture within the sac ; and if 
the gut should be gangrenous it will not be discovered. 

Usually the cord will be found behind the sac, but sometimes it 
is split up, and its constituents found lying upon the sac ; caution is 
then required to avoid wounding the artery and duct. 

The operation for direct or ventro-inguinal hernia, is very much 
the same. There will be no cremasteric covering, but in place of it 
an expansion of the conjoined tendon of the internal oblique and 
transversalis muscles ; sometimes this is wanting, owing to the ten- 
don having been split, especially if the protrusion is sudden, and 
the result of great violence. 

In a concealed inguinal hernia, the tendon of the external oblique 
.must be divided, as well as the lower portion of the internal oblique 
and transversalis muscles. 

FEMORAL HERNIA. 

This is most common in women, owing to the natural form of the 
pelvis. The descent occurs at the crural ring; in order to under- 
stand which, it will be necessary to refer to the anatomy of the part. 
(See Anatomy, page 92.) 

The tumour is more spheroidal usually than in inguinal hernia, 
and will be found to be beneath Poupart^s ligament, instead of above. 
The fundus of the tumour is bent upon its neck, which curvature 
must be attended to in producing taxis. Strangulation is more 
common and more severe than in inguinal hernia. 

Fig. 22. 




The operation for the relief of stricture is thus performed. The 
patient being properly placed upon a table, and the parts being shaved, 



82 SURGERY. 

the skin is pinched up and divided by transfixion, in order that there 
may be no injury to the important parts beneath. The wound of 
the skin may be crucial in shape, or resemble an inverted T. 

After dividing the skin, the superficial fascia is exposed; this 
being divided, the fascia propria is brought in view ; that fascia is 
sometimes much blended with the sheath of the vessels. Under the 
fascia propria will be found the hernial sac. It is opened in the same 
cautious manner as before, when a smaller quantity of fluid will 
escape than in inguinal hernia, and the convolution of intestine be 
readily recognised. The seat of stricture is then to be sought ; it 
may be at Hey's ligament, at Grimbernat^s ligament, or at the mouth 
of the sac. The stricture is to be divided with great care, for fear 
of an irregular origin of the obturator artery, the neck of the sac , 
being surrounded by it. 

The gut being returned, the after treatment will be the same as 
in inguinal hernia : the patient is to be kept in a recumbent position, 
and under antiphlogistic regimen. If there is no movement of the 
bowels in the course of several hours, a dose of castor oil may be 
given, or a mild enema may be useful ; should there be inflamma- 
tory symptoms, leeches, calomel, and opium will be serviceable. 
Occasionally the patient is troubled with tympanites and flatulence, 
which will be relieved by a carminative, or enema of turpentine. 

UMBILICAL HERNIA. 

This is common in infants in whom the umbilicus is not consoli- 
dated. It is produced by crying ; and appears as a soft, compressi- 
ble tumour. 

It occurs also in women who have borne many children ; though 
in them the point of the protrusion is not through the navel, but 
near it. 

Strangulation does not often take place. 

The treatment in a child is simple and effective. A small hemi- 
spherical pad, made of cork, or half of a nutmeg, covered with 
buckskin, is properly fitted, and there secured by a broad strip of 
adhesive plaster, which should surround the belly of the child. 

In the adult the tumour may become very large, and usually con- 
tains a large quantity of omentum. Pain, indigestion, and consti- 
pation are often its accompaniments. The treatment consists of a 
large truss, adapted to the case. In case it should be strangulated, 
the operation for relief of the stricture is performed by making an 
incision through the skin and superficial fascia, which exposes the 
sac ; this is to be opened in the usual manner. The incision for the 
relief of the stricture is to be made in the linea alba. 



FISTULA IN ANO. 83 



OTHER VARIETIES OF HERNIA. 



SCROTAL UERNIA. 



Is a term applied to the protrusion of intestine when it has de- 
scended from the groin into the scrotum. It occasionally entirely 
obscures the penis^ and reaches almost to the knees. Its coverings 
are those of inguinal hernia. 



CONGENITAL HERNIA. 



This depends upon a want of obliteration of the connexion be- 
tween the peritoneum and tunica vaginalis of the testicle. The in- 
testine descends in the same manner as the testicle. It has no sac 
or peritoneal covering other than that in which it and the testicle 
are contained. 

This is most common in young male children^ and is easily cured 
by a truss ; there being a natural tendency to closure in this tubular 
connexion between the peritoneum and tunica vaginalis. Care 
should be taken in the application of the truss or compress, not to 
injure the spermatic cord. 

In very young children a graduated compress and roller will effect 
a cure if properly applied. 

VENTRAL HERNIA. 

Is a protrusion of the intestine at any part of the belly except 
the navel and groin ; and it may be the result of a bruise, wounds, 
and unnatural weakness of the muscles of the abdomen. 

VAGINAL HERNIA. 

Is a protrusion of the intestine into the vagina. 

PERINEAL HERNIA. 

When the tumour is in the perineum, having descended between 
the bladder and rectum. 

PHRENIC OR DIAPHRAGMATIC HERNIA. 

Is a protrusion through an opening of the diaphragm. 

The intestine is sometimes strangulated within the cavity of the 
abdomen, through an opening in the mesentery, or meso-colou, or 
some portion of peritoneum, or peritoneal band, resulting from in- 
flammation. 

DISEASES OF THE RECTUM. 
FISTULA IN ANO. 

A Fistula is said to be complete when a sinus communicating with 



84 SURGERY. 

the bowel, opens upon the nates; when it does not communicate 
with the bowel, but opens externally, it is called a blind external 
fistula ; when it opens internally but not externally, it is called a 
blind internal fistula. 

If complete, there is discharge of pus, feeces, and wind, and it is 
attended with heat, uneasiness, and pain. The sinus is sometimes 
very tortuous, and often multilocular. The internal orifice is usually 
about an inch and a half above the anus, but sometimes higher. 
The cause producing it may vary. It may originate in an inflam- 
mation of the rectum, or by an abscess external to it. It is very 
frequently connected with phthisis caused by the constant cough in 
that disease. 

The treatment for complete fistula is generally that of the knife, 
the object being to place the part at rest, and convert the sinus into 
an open sore. The bowels having been entirely emptied, the index 
finger of one hand being oiled, is introduced into the rectum^ and a 

Fig. 23. 




probe-pointed bistoury is introduced through the sinus into the gut, 
so that its probe touches the finger ; thus kept in contact, both finger 
and bistoury are withdrawn, completely laying open the sinus, and 
dividing the sphincter ani muscle. Any bleeding vessel is to be 
tied ; hemorrhage by oozing is to be stopped by stuffing with lint ; 
a small portion of lint is to be placed between the lips of the wound, 
so as to prevent their closure; the object being to^make the whole 
track inflame, granulate, and heal from the bottom. After the 
operation, a dose of morphia may be given to promote quietness and 
sleep ; and after three or four days a dose of castor oil, which will 
bring away the contents of the bowel, and the dressings of the 
wound. Subsequently it will only be necessary to attend to clean- 
liness, and prevent the edges from uniting. 

If the opening be very high in the rectum, it is better to use the 



HEMORRHOIDS. 85 

ligature in preference to the knife, on account of the danger of 
hemorrhage from the hemorrhoidal arteries. The ligature only is 
to be used in phthisical cases ; it gradually cuts itself out, and 
leaves the part solid behind it. A blind fistula may be readily 
converted into a complete one by puncturing the intestine should it 
be an external fistula, or the skin in case it should be an internal one. 

FISSURE OF THE ANUS. 

This is an ulceration or cracking of the skin and mucous mem- 
brane, on the verge of the anus ; and is attended with intense pain, 
especially upon going to stool. It results very often from dyspepsia, 
and this circumstance must materially aifect the treatment. Alte- 
ratives and laxatives are necessary to bring the bowels into a healthy 
condition. The local applications are caustics and anodynes, such 
as nitrate of silver, which has a soothing as well as antiphlogistic 
power; opium, in the various forms of ointment, solution, and 
poultice. Sometimes it is necessary to excise the part, or divide 
the sphincter ani muscle. 

HEMORRHOIDS. 

Piles, or hemorrhoids, are divided into external and internal. 
They are more common in males than in females, and rarely occur 
in children. The predisposing causes are v/hatever tends to deter- 
mine the blood to the rectum, such as constipation, pregnancy, 
sedentary habits; and the exciting causes may be purging^ diar- 
rhoea, &c. 

EXTERNAL PILES. 

Are a congeries of varicose veins, surrounded by condensed cellu- 
lar tissue. In some cases, bleeding occurs from ulceration of the 
skin or mucous membrane covering them. When they do not 
bleed, they are said to be blind. When the blood has coagulated, 
they become hard. Usually, there is more than one. 

The palliative treatment consists in the application of astringent 
and anodyne ointments, made of galls, opium, &c., and the regula- 
tion of the bowels with laxatives, such as sulphur, rye-mush with 
molasses, &c. 

The radical treatment is removal by scissors or bistoury ; arrest- 
ing the hemorrhage, and producing a healthy ulcer. A recent 
tense, single pile, may be successfully cured sometimes by freely 
evacuating its contents by a lancet. 

INTERNAL RILES. 

May be of the same nature as external ones, or of a sarcomatous 
character; but more frequently they consist of an abnormal develop- 



86 SURGERY. 

ment of the submucous cellular tissue, having the nature of erectile 
tissue ; the tumour has a broad base, and its surface resembles a 
strawberry ; at stool they protrude, and are attended with hemor- 
rhage. The general health will suffer by emaciation, indigestion, 
pain, and there may result fistula, prolapsus, and disease of the 
genital organs. 

Treatment. — In the first place, the stomach and bowels must be 
regulated by laxatives; — disorder of the liver must also be cor- 
rected, since any obstruction of the portal circulation in that organ 
predisposes to hemorrhages, or congestion of all the chylopoietic 
viscera; there being no valves in the veins forming the portal vein. 
Great benefit will result from the use of astringent injections, such 
as solutions of zinc, oak bark, &c. ; but the radical cure consists in 
the removal of them, by strangulating with a ligature or wire ap- 
plied by means of a double canula. 

Piles should not always be cured in elderly persons, especially 
those with tendency to diseases of the head. 

PROLAPSUS ANI. 

This is an eversion and protrusion of the rectum beyond the 
anus, and is dependent upon relaxation. 

The extent of the protrusion varies much in different cases; 
in some instances being confined to a small portion of the mucous 
membrane ; in others, the rectum, and perhaps a portion of the 
sigmoid flexure escape. In children, worms, diarrhoea, straining, 
and crying, may promote the disease. In old persons, it is brought 
on by enlarged prostate, stone, coughing, &c. When the gut habi- 
tually descends, the tumour is red and large. 

The treatment consists in removing the cause ; in regulating the 
bowels, and carefully replacing the intestine after each protrusion. 
The evacuations should be made in the recumbent position. 

The general habit should be invigorated by tonics, and the tumour 
should be bathed with cold astringent washes. It may be necessary 
to lubricate the parts before reducing them, and afterwards a T 
bandage should be worn, to prevent the prolapse. 

In extreme cases, operations have been performed. A fold of the 
mucous membrane has been removed, in order to contract the in- 
testine ; and a portion of the sphincter has been cut out, in order 
to diminish the orifice of the anus. 

ENCYSTED RECTUM. 

This consists of an enlarged and diseased condition of the sacs of 
the mucous membrane of the rectum, just above the anus. 

The treatment consists in drawing down the sacs with a bent 
probe, and excising them with a pair of scissors. 



URINARY CALCULUS. 87 



IMPERFORATE ANUS. 

This is a congenital imperfection. The rectum terminates in a 
cul de sac, at various distances from the ordinary location of the 
anus ; in some instances, it is so near the skin as to form a promi- 
nence, by the constant collection of fgeces. In such cases, the opera- 
tion is easy and simple : a free opening being made in the proper 
direction, with regard to the bladder or vagina, the meconium escapes, 
and the edges are prevented from uniting, by the interposition of a 
piece of lint. In other instances, it is impossible to reach the cul 
de sac ; then it is necessary to form an artificial anus. This is done 
by opening the descending colon immediately under the left kidney, 
making the incision through the skin and fascia, so as to expose the 
posterior portion of the bowel, which is not covered by peritoneum 
at this part ; a sphincter is said to be formed in the loins, though 
it is necessary to wear a pad. 

URINARY CALCULUS. 

Calculi are generally formed in the kidneys by a precipitation of 
earthy substances, and when they pass freely and frequently, the 
disease is termed gravel ; when they are retained and become large, 
the disease is called stone. 

The symptoms of stone in the kidneys are pain in the lions, irri- 
tation and retraction of the testicle, bloody urine, and inflammation 
of the kidney. The passage of the stone through the ureter causes 
most acute and severe pain in the loins and groin, faintness, and 
sickness of stomach, which may last for several days, and is only 
relieved by the stone entering the bladder. 

The treatment for 2ifit of the gravel, as these attacks are called, 
consists in bleeding, warm bath, large doses of opium, soothing 
enemata, diluent and diuretic drinks, spirits of turpentine, &c. 
The ordinary result is the passage of the calculus ] but sometimes 
it is retained in the kidney, increasing in size, and assuming the 
branching form of the pelvis, calices, and infundibula. It does 
not always produce inconvenience, but generally is attended with 
wasting of the organ, or suppuration, the abscess bursting into the 
colon or loins. 

A small calculus, lodging in the bladder, and not being dis- 
charged through the urethra, serves as a nucleus for further deposit ; 
any foreign body, such as a needle, drop of blood, or bullet, may 
serve, also, as a nucleus. The symptoms of stone in the bladder 
are, frequent, sudden, irresistible, unrelieved desire to make water; 
pain in the glans penis, and elongation of the prepuce ; sudden 
stoppage of the stream in urination, and its re-establishment by 
change of position — the urine being mixed with mucus and some- 
times with blood ] but nothing but a sound can positively prove its 



bb SURGERY. 

existence. Many of the symptoms are simulated by other diseases, 
such as stricture of the urethra, enlarged prostate, irritable blad- 
der, &c. The rectum sympathizes, especially in children, and he- 
morrhoids or prolapsus ani are apt to occur. Stones vary in their 
form, size, colour, consistence, and chemical composition ; some are 
rough on their surface, others smooth ; they are more frequently of 
an oval shape. The size may be that of a pea, or that of a goose- 
egg. The most common colour is a light brown ; some, however, 
are nearly white, others nearly black. Some are soft and friable, 
and crumble easily; others are flinty, and require great force to 
fracture them. 

They are most generally composed of lithic or uric acid, lithate 
of ammonia, phosphate of lime and magnesia, oxalate of lime, and 
carbonate of lime. The lithic acid stones are perhaps the most 
common : they are oval, flattened, of a fawn-colour, and consist of 
concentric laminse; the phosphatic stones are high-coloured and 
friable. The oxalate of lime forms the mulberry calculus, which is 
the hardest stone, of a very dark colour and a very rough surface. 
The number existing in the bladder at once, may vary from one to 
several hundred. 

The formation of stone is consequent upon a derangement of 
health, deficiency of exercise, indulgence in animal food, defective 
condition of the skin, and dyspepsia. It is also dependent upon 
climate, age, locality, and hereditary influences. The immediate 
cause in every case cannot be discovered; some suppose that the 
character of the water drank influences its production. Stones are 
sometimes encysted in the prostate gland and urethra. 

Treatment. — Gravel may be prevented or mitigated by attention 
to the skin and digestion, the use of acids or alkalies, dependent 
upon the diathesis of the patient manifesting the disease ; but, after 
stone has been lodged in the bladder, it cannot be removed by medi- 
cines : surgical means must be resorted to. 

Sounding. — This requires great tact and care in its performance, 
and must only be attempted when the condition of the patient is 
most favourable; if performed immediately after a journey, or dur- 
ing a fit of the gravel, the consequences might be serious, A sound 
is a solid steel instrument, resembling a catheter in shape, but hav- 
ing its curvature much nearer the extremity, and a broad flattened 
handle. The patient should be placed in a recumbent position, and 
the urine retained in the bladder for some time previous to sounding. 
The instrument being carefully introduced, can be moved about in 
the bladder, and when the stone is touched, a distinct click will be 
heard, and a sensible impression of impingement will be felt. 
There are many sources of error in sounding : the instrument may 
pass over the stone, when lodged in the inferior fundus of the 
bladder, or the stone may be small and encysted in the mucous 
coat ; on the other hand, we may be deceived by the sound grating 



LITHOTOMY. 89 

against a diseased prostate or sandy matter in the urethra. In case 
of difficulty in detecting a stone, it is better to repeat the operation 
frequently, the patient being placed in different postures, than to 
prolong the exploration, at the risk of producing inflammation of 
the bladder. Having detected the stone, it is possible to form 
some idea of the size and number by sounding. Some have at- 
tempted the disintegration of the stone by injecting various solutions 
into the bladder ; but the most common operations are Lithotomy, 
Lithotrity, and Lithotripsy. 

LITHOTOMY. 

This is an ancient operation, modified and improved in modern 
times. It is to be performed in children and in old persons, when 
the stone consists of the oxalate of lime, and when there is stricture, 
or diseased prostate. 

The different modes of performing the operation are the lateral, 
high, and bilateral. The lateral is most common, and is performed 
in this manner. 

The patient, having been properly prepared by emptying the 
bowel and retaining the urine in the bladder, is placed upon a table 
of convenient height, and firmly bandaged hand to foot, with his 
knees elevated. A staff as large as the urethra will admit, and 
deeply grooved on the convex and left side, is then introduced. 
Two assistants separate the knees, so as to expose the perineum, 
which ought to be cleanly shaved. The patient is then to be 
brought to the edge of the table, and the surgeon seats himself in 
front with his instruments in good order, and conveniently at hand. 
The staff, being brought in contact with the stone, is well hooked 
up under the symphysis pubis, and not pressed down upon the rec- 
tum, and then given to a third assistant, who is directed to hold it 
vertically, and also charged with keeping the scrotum out of the 
way. 

An incision is made with a scalpel in the direction of the dotted 
line of the drawing (Fig. 24), of about three inches in length, 
commencing about one inch behind the scrotum, and extending 
downwards and outwards to a point between the anus and tubero- 
sity of the ischium, and even beyond it. Various measurements 
are given by different surgeons as to the point at which this is to be 
commenced. No well-informed surgeon should depend upon an 
absolute measurement, on account of the difference which exists in 
different patients, with reference to the size and depth of the peri- 
neum. He should inform himself of the probable size of the pros- 
tate gland by an examination per anum, and then, by his anatomical 
knowledge, make his incision so as to expose the membranous por- 
tion of the urethra, taking care not to cut the bulb of the corpus 
spongiosum in front and the rectum behind. Having cut through 

8^ 



90 



SURGERY. 



the skin and superficial fascia of the perineum, which is very thick, 
especially in fat persons, the transversus perinei muscle, the trans- 
Fig. 24. 




versus perinei artery, the lower edge of the triangular ligament, 
and it may be a few fibres of the levator ani muscle, must then be 

Fig. 25. 




divided. By an examination with the finger, the staff may now be 
felt in the urethra. By means of the finger and nail this space 
should be increased, and the urethra opened by a bistoury, which 
will be indicated by a flow of urine. The gorget should now be 
introduced into the wound, with its beak securely fixed in the 
groove ; it is then pushed in the direction of the bladder, cutting 



LITHOT.OMY. 91 

through its neck and prostate gland. Care must be taken to depress 
the handle of the gorget whilst making this thrust, for fear of 
wounding the rectum. Urine gushes out, the gorget is carefully 
removed, for fear of wounding the internal pudic artery, and the 
finger introduced into the bladder to discover the stone, its position, 
and size. A strong pair of forceps are then introduced, and the 
stone grasped in such a way that its short diameter shall engage in 
the wound, whence it is to be delivered slowly and gradually. 

If it be impossible to remove the stone through this opening, it 
may be enlarged with care, on the same, or, if necessary, the other 
side. After its removal, the finger must again be introduced, to see 
if there is another stone. 

The bladder being freed from all calculus by the forceps or sy- 
ringe, a tube is introduced into the bladder through the wound, by 
which the urine is to escape. The patient is then put to bed, with 
the knees placed together. A small cup or saucer receives the urine 
from the tube. Severe hemorrhage may result from a wound of 
the bulb of the corpus spongiosum, or from cutting the urethro- 
bulbar artery. If a ligature cannot be applied, it must be com- 
pressed by the finger as long as may be necessary. 

There may also be a venous or arterial oozing, which is to be 
arrested by removing the tube and cramming the wound with lint, 
a catheter being introduced through the urethra. Should there be 
no hemorrhage, the tube is to remain until the wound has granu- 
lated around it, and the urine has commenced to fiow from the ure- 
thra. 

Some prefer to open the bladder with a scalpel, having confi- 
dence in their anatomical knowledge, and considering the gorget as 
a clumsy instrument, a remnant of olden times. Others use a con- 
cealed bistoury, cutting either upon one or both sides of the ure- 
thra. * Besides which are various instruments, modifications of the 
gorget, and scalpels with beaks attached. 

In four or five weeks the wound is healed. 

The high operation is performed by making an incision through 
the linea alba, opening the bladder where it is not covered by peri- 
toneum. This is only necessary where the stone is of enormous 
size, the prostate diseased, or the space between the tuberosities of 
the ischia contracted. 

Stone in toomeny is much less frequent than in men, because the 
renal calculus is more readily passed by the urethra. Should it be 
retained, and increase in size, it may be removed b}' dilating the 
urethra sufficiently, or by the lateral operation, making the incision 
from the orifice of the urethra, and through the neck of the blaJJor. 
Incontinence of urine is apt to follow. 

The rccfo-vesical operation consists in cutting into the bladder 
from the rectum. 



92 



SURGERY. 



LITHOTRITT. 



Lithotrity signifies the boring or drilling the stone, and has been 
most successfully accomplished by Civiale. His instrument con- 
sists of a straight canula containing a drill and three claws which 
can be protruded after its introduction into the bladder. These 
claws are equally liable to catch the coats of the bladder as well as 
the stone, and the operation has been superseded by the following. 



LITHOTRIPSY. 



This implies the crushing of the stone whilst in the bladder ; and 
it is preferred to all other operations for disintegration. 

The cases most favourable for this operation are adults, where the 
urethra is free from stricture, the bladder free from irritability and 
not contracted, and the prostate not enlarged. A mulberry calculus 
would be unfavourable for lithotripsy, on account of its hard cha- 
racter. 

The instrument most frequently used is that of Heurteloup, or a 
modification of it. It consists of two blades, which slide one upon 

Fig. 26. 




the other, the extremities being slightly bent. It can be introduced 
into the bladder as a sound or catheter, and afterwards the blades 
are separated, to grasp the stone. In the original instrument the 
male blade was struck with a hammer, and thus the stone was 
broken ; now the crushing power is that of a screw, variously 
adapted, — that of Mr. Weiss being most simple and perfect. 

The extremities of the instrument have teeth, so as to retain the 

stone when grasped, and 
Fig. 27. also fenestrge to allow of 

the escape of sand or pow- 
dered stone. 

The patient must be pre- 
viously prepared for the 
operation, by regulation of 
the general health, dilata- 
tion of the urethra, and 
distension of the bladder. 
The patient lies on a con- 
venient table or bed, with 
the pelvis elevated, so as to 
throw the stone into the 




GONORRHCEA. 93 

fundus of tlie bladder; the bladder must be full, so as to prevent 
its coats from being entangled in the instrument. If urine cannot 
be retained, tepid water must be injected. The instrument must 
be oiled and warm. 

After encountering the stone and fairly grasping it, an operation 
which requires tact in manipulation, the stone is crushed by slowly 
and gradually turning the screw. Then the instrument should be 
withdrawn, and when the irritation has subsided, subsequently in- 
troduced to crush the fragments. Thus many operations may be 
required to reduce the stone into fragments sufficiently small to pass 
the urethra. 

It is not to be expected that fragments will escape at the first 
urination : the after treatment should consist of diluent drinks, and 
bland injections to accelerate their passage; and it may be that the 
hip-bath, anodyne enemata, and leeches, will be required. The 
sources of danger are the irritability of the bladder, and urethra ; 
inflammation often resulting from the irregularity of the fragments, 
and too frequent introduction of the instrument. Sometimes frag- 
ments are arrested in their passage through the urethra : a bougie 
or catheter should be introduced, of large size,, and the fragment 
pushed back into the bladder : should it become impacted it may 
require a special instrument for its extraction, or an incision in the 
perineum. 

Jacohson^s instrument is used by many. Its extremities are con- 
nected by a link : thus a loop is formed to grasp the stone when 
the blades are separated in the bladder. By the operation of the 
screw, the female blade is pulled upon the male ; whereas in Heurte- 
loup's the male is pushed upon the female, — thus there is less dan- 
ger of fine fragments or sand being caught between the blades of 
the latter, which would impede the movement. 

VENEREAL DISEASE. 

The history of this disease is involved in some obscurity, although 
it is generally believed to have existed from the earliest ages. It 
consists of GonoiThoea and Sj/iyJiiliSj which are usually considered 
as distinct diseases, although there are high authorities to the con- 
trary. 

GONORRHCEA. 

Gonorrhoea is an acute inflammation of the lining membrane of 
the urethra, commencing in its anterior portion. It is caused by 
matter from another, during sexual intercourse. In about five days 
a discharge appears, although it may occur in a low hours^, or not 
until ten days after coition. 

Symptoms. — Heat, itching, redness of the glans, and swelling of 
the orifice of the urethra; the stream of urine is small and attended 



94 SURGERY. 

with burning and smarting ; the swelling, redness, and pain increase ; 
the discharge is no longer limpid, but turbid, puriform, and pro- 
fuse, sometimes being mixed with blood; the thighs, loins, testi- 
cles, and groins sympathize in a dull pain, and there may be fever. 
Chordee may occur, which is an intensely painful erection of the 
penis, which is bent like a bow, with the convexity upwards : this 
is owing to the corpus spongiosum being filled with lymph, which 
prevents its expansion by blood. It is aggravated by the warmth 
of the bed, and voluptuous dreams. 

The glans may become excoriated; the prepuce oedematous, in- 
ducing phymosis ; a sympathetic bubo may form in the groin, or an 
abscess in the perineum. 

The joints may be painful as in rheumatism ; the testicle swell 
and inflame, constituting orchitis, especially if the patient is impru- 
dent in exercise, during which the discharge diminishes. As the 
orchitis declines, the discharge reappears. 

Gonorrhoea is capable of self-cure ; the symptoms gradually sub- 
siding, and the discharge diminishing, and becoming mucous in its 
character : it is then a gleet^ which is without pain, redness, &c., 
but which is readily rekindled into an inflammatory gonorrhoea by 
imprudence in diet or exercise. 

Treatment' — In the earliest stage, the ectrotic or abortive plan 
may be pursued, if the discharge has not reached the suppurative 
crisis. A strong solution of nitrate of silver, used properly with a 
glass syringe, may cut short the disease at the outset. It should be 
used but once or twice, and acts by neutralizing the virus, as an 
antiphlogistic, and also coats the urethra with a film which protects 
the villous surface. This treatment often fails, especially in irritable 
temperaments, and when not used in the earliest stage ; and if not 
succeeding, is followed by an aggravation of symptoms. 

In the treatment of gonorrhoea, it is to be remembered that the 
first attack is generally the most severe; hence the importance of 
rest, which is seldom complied with. Low diet, purging, and tartar 
emetic as an antiphlogistic and antaphrodisiac ; opium and cam- 
phor are also useful at night, in preventing painful erections and 
chordee; a warm bath is most serviceable. Mucilaginous drinks 
may mitigate the ardor urinas. Leeches and ice to the perineum 
are sometimes very advantageous. 

The discharge now must not be suddenly arrested, else by meta- 
stasis the testicle, bladder, or prostate become involved. Strong 
injections are very injurious, although they may temporarily arrest 
the discharge. As the inflammatory symptoms subside, weak 
astringent injections may be used with a glass syringe : sulphate of 
copper, zinc, alum, or iron, in the proportion of half a grain to the 
ounce of water. 

Cuhehs and copaiba are remedies which seem to exert a specific 



SYPHILIS. 95 

influence on the urethra : the latter may be given in almost all 
stages of the disease , but the former should be restricted in its ad- 
ministration to the latter stage. These medicines often do harm, 
when persevered in too long, by inducing a chronic disease of the 
bladder, attended by a slight discharge. In the chronic stage of 
the disease, the discharge may be benefitted by weak solutions of 
nitrate of silver, and a weak solution of chloride of zinc. In a gleet, 
a large bougie introduced into the urethra, will oftpn prove of imme- 
diate service. 

Spurious gonorrhoea, or balanitis, is a discharge from the prepuce 
and glans, often induced by want of cleanliness, or gonorrhooal mat- 
ter. A solution of nitrate of silver, and frequent application of cold 
water will cure it. 

Wai'ts are to be removed by the scissors or knife, and their bases 
touched with nitrate of silver, or nitric acid. 

Women suffer less than men, although the vagina is involved as 
well as the urethra. The symptoms are the discharge, swelling, 
pain in micturition, sitting, and walking, aching in the back and 
loins. 

The treatment is upon the same principles as in men ; stronger 
injections may be used without the danger of stricture ; and lint 
saturated with medicated solutions, retained in the vagina. Young 
girls suffer from spurious gonorrhoea and leucorrhoea, from which 
they are to be carefully distinguished. Leucorrhoea is chronic in 
its character from the first, attended with lassitude, pain in the 
back, pallor, irregular menstruation, and the urethra is not involved 
generally. 

SYPHILIS. 

This term comprises all diseases resulting from a certain virus. 

Primary Symptoms. — After one or two days' incubation of the 
virus, the pustule forms, and the ulcer is established at the sixth 
day. It is first attended with redness, itching, and heat ; then a 
vesicle appears, becomes purulent, breaks, and an ulcer is formed. 
This is circular or oval, excavated, and pale, with a bright red 
areola ; the discharge is thin, ichorous, and infectious ; finally, 
flabby granulations and cicatrization. If the virus touches an abra- 
sion, the sore may appear at once. This sore is not to be mistaken 
for a common ulcer, or abrasion, or herpes. Most frequently it is 
situated on the collum behind the corona; the most unfavourable 
position is the frocnum, which it often destroys. 

Treatment. — If the ulcer is freely cauterized before the sixth day, 
the poison is destroyed, the ulcer converted into a simple one, and 
the system is uncontaminated. After the application of nitrate of 
silver, water may be used, or water medicated with aromatic wine, 



96 SURGERY. 

or chloride of soda : granulation and cicatrization are treated as in 
any other case^ and thus a simple venereal ulcer heals. 

HTJNTEILIAN OR TRUE CHANCRE. 

The sore is circular^ much excavated^ with hardened base and 
edges ; and the surface is of a tawny or brownish hue, covered by 
a thin pellicle. It occurs most frequently on the glans penis or the 
skin^ and is usually solitary, and has no areola. 

It is to be treated by the application of lunar caustic, and the in- 
ternal administration of mercury and iodide of potash. Mercury 
hastens the cure of the primary sore, and affords security against 
secondary consequences, especially of the Hunterian chancre ] some 
general constitutional treatment may also be necessary. Blue pill 
may be given every night and morning, until the gums are slightly 
sore, and there is a slight increase of saliva : its action should be 
maintained at this point for several weeks. 

PHAGEDENIC CHANCRE. 

This is rapid in its progress and painful; the surface yellow, 
and dotted with red streaks ; the shape irregular ; edges ragged 
and undermined; their discharge is thin, profuse, and sanious. 
These ulcers eat deeply into the skin of the penis and surrounding 
parts. This chancre is apt to occur in those whose constitution is 
broken down with drink, debauchery, prostitution, and mercury; 
mercury usually aggravates it. 

Treatment. — As a local application, the nitrate of mercury is 
most beneficial ; the chloride of zinc is also calculated to arrest the 
spread of the disease. The constitution must be supported with 
tonics, stimulants, and good diet. 

BUBO. 

Bubo is an inflamed lymphatic vessel or gland leading from a 
venereal ulcer ; the glands may inflame from a wound of the foot 
or from gonorrhoea, but a real syphilitic bubo is the result of ab- 
sorbed virus. Buboes vary in the rapidity of their develpment, and 
some are termed acute, others chronic ; the former hastening to sup- 
puration, whilst the latter are indolent. If one gland only is affected, 
and that above Poupart^s ligament, it is most probably caused by 
chancre, if one exist ; but if many glands are swelled, and they are 
below this ligament, their swelling is probably the result of irrita- 
tion. Inoculation is the surest test. 

Treatment. — An acute bu-bo will oYten yield to rest, leeches, 
fomentations, &c., but if the venereal virus shall have created pus 
in the interior, leeches and cold applications will rather retard the 
cure. Poultices, and early evacuations, are then most to be relied 
on. Extensive collections of pus, and sinuses, are often the result 



STRICTURE OF THE URETHRA. 97 

of delay in eliminating the virus. The opening of a Lubo at an 
early stage with a sharp lancet, even should no pus exist within^ 
empties the congested vessels, and rather promotes a cure. Blisters 
and iodide of potassium will be found of use in assisting in absorp- 
tion. In an indolent bubo an alterative course of mercury^ and 
good diet are necessary. 

Constitutional Symptoms. — These are secondary and tertiary. 

The secondary symptoms speedily follow the jorimary, usually 
during the second month ; consisting chiefly of general eruption, 
affection of the throat, fever, change of complexion, dryness of hair, 
rheumatic pains in shoulder and knee, headache. Different kinds of 
eruption follow different kinds of primary sore, although there may 
be irregularity in this respect. Periostitis is apt to manifest itself 
in the shins. Secondary symptoms are transmissible from husband 
to wife, wife to child, child to nurse. 

Treatment. — The object is to assist nature in the elimination of 
the poison ; hence we should not suppress the eruption, but act on 
the skin, kidneys, bowels, and other organs of excretion. The throat 
should be fomented, and touched with nitrate of silver. Mercury is 
not to be used if possible, especially in scrofulous, weak temperaments, 
or when the constitution is broken by dissipation, or the previous 
abuse of mercury. Small doses of corrosive sublimate, or the protio- 
dide of mercury, is the best form of administration. But the iodide 
of potash is the most effective remedy in this disease. It is given in 
doses of 4 or 5 grains three times a day. Baths are most impor- 
tant; sometimes their value is increased by medicating them. Sul- 
phur, and weak solutions of mercury seem to exercise the best in- 
fluence upon the local affections of the skin. 

Tertiary Symptoms. — These seldom occur, except after the worse 
kinds of sore, unless mercury has been rashly used. The perios- 
teum and bones are affected by a chronic inflammatory process. 
Suppuration, caries, and necrosis result; also, stiff joints, tubercular 
formations of the skin, and condylomatous tumours. Destruction 
of the gums, cheeks, deafness, and iritis are also among the conse- 
quences. These symptoms are not transmissible. 

Treatment. — More dependence is to be placed upon the iodide of 
potassium, than any single remedy. The general remedies will 
consist of bathing, regimen, and alteratives. Opium and blisters 
are necessary to relieve the pain in the bones at night. 

DISEASES OF THE URINO-GENITAL ORGANS. 

STRICTURE OF THE URETHRA. 

S r A S ^I O D I C STRICTURE 

Depends on spasm of the muscles connected with the membranous 

9 



98 SUROERY. 

portion of tlie urethra. It generally occurs in persons with some 
permanent obstruction ; exposure to cold^ and indulgence in drink 
also favour an attack, which usually occurs after dinner. Cantha- 
rides absorbed from blisters produces the effect. 

Si/mptoms. — Sudden retention of urine ; great straining and de- 
sire to urinate; the bladder becomes distended, the countenance 
anxious^ the pulse quick, the skin hot ; at last the bladder bursts, 
and extravasates into the peritoneum, or perineum. 

INFLAMMATORY STRICTURE. 

This is another variety of the above, generally caused by abuse 
of injections, exposure, or intemperance during acute gonorrhoea. 

Treatment. — A catheter should be introduced at once. This is 
managed by introducing as large an instrument as the parts will 
admit of, and stretching the penis forward on the catheter, whose 
point at the same time should be directed towards the upper surface 
of the urethra, and pressed steadily, but gently, against any obstruc- 
tion. Relaxation of the spasm may also be produced by bleeding, 
warm bath, Dover's powder, laudanum enemata, and cold water upon 
the genitals. Should all these means fail, and life be endangered, 
the bladder should be punctured from the rectum, or opened by a 
perineal section. 

PERMANENT STRICTURE. 

This is a contraction from permanent inflammation, plastic deposit 
having taken place in the submucous cellular tissue. The occasion 
of this inflammation may be clap, venery, kicks or blows, riding on 
horseback, acrid urine, drinkings, &c. The most frequent sites are 
at the commencement of the membranous portion of the urethra, 
and also within a few inches of the glans penis. The extent and 
degree of contraction vary : sometimes the stricture is ^qyj tight, 
but limited, as if a thread had been tied around the urethra; more 
frequently it is of greater extent, continuing from a quarter of an 
inch to several inches. Several strictures may exist at once. Behind 
the stricture the urethra is enlarged, and serves to catch a calculus. 

Si/mptoms. — These come on gradually : middle-aged men are most 
liable. Urination is frequent, tedious, and painful : the stream is 
thin, twisted, or forked. After urination a few drops pass which had 
collected behind the stricture. Pain in the perineum, thighs, and 
loins; erection is often painful : semen does not escape in coition, 
but passes into the bladder, and afterwards is voided with the urine ; 
chill and fever constantly occurring, as in ague : a slight discharge 
is visible at the end of the penis upon rising in the morning; the 
testicles, rectum, and bowels sympathize, and the general health 
fails. 

Treatmert/. — 1st. Dilatation by bougies of flexible metal, silver, 



INFLAMMATION OF THE BLADDER. 99 

or gum elastic, of sufficient size, since small bougies are more apt 
to be entangled than large ones. The natural structures are not to 
be mistaken for strictures, viz., an enlarged lacuna in the fossa; 
spasmodic contraction of the accelerator urinsc muscle ; the trian- 
gular ligament, and prostate gland. The operation must be fre- 
quent and cautious until the cure is complete, and even afterwards, 
to prevent return of this disease, which is not uncommon ; indecl 
there is no certainty that it will not return. 2d. Caustic applied 
firmly to the stricture ; it destroys irritability, but is more advan- 
tageous in stricture near the glans than the bladder. 3d. Punctu- 
ratiouy by means of a lanceted stilet, introduced concealed in a 
silver canula; after the division, a catheter is to be introduced. 4t]i. 
Opening the ttrethra through the perineum, resembling a lithotomy 
operation ; a catheter is then introduced into the bladder, and the 
wound heals over it. 

FISTULA IN PERIN^O. 

This is usually the result of abscess of the perineum, or a wound. 
The patient has rigors, fever, and an exquisitely painful promi- 
nence in the perineum, which opens and discharges, much to the 
relief of the sufferer. The opening, however, often remains, and 
through it the urine dribbles. This abscess may be caused by a 
kick, or urinous infiltration from an internal fistula, produced by a 
stricture. 

Treatment. — This should be directed to the cause; if a stricture 
exist, this should be cured first, and then the fistula, by caustic 
application, the application of a red-hot wire, or by paring the edges. 

ENLARGED PROSTATE. 

The gland is enlarged, from chronic infiammation, brought on by 
gleet, stricture, horse exercise, &c. ] it is most common in middle 
life, and disappears upon the removal of the cause. Leeches, rest, 
counter-irritation, iodide of potash, laxatives, and enemata, are the 
proper treatment. But the gland is also enlarged in old persons, — 
a hypertrophy independent of inflammation. This cnlargemenr 
takes place first in the middle lobe, and the lateral lobes enlarge 
unequally. The bladder sympathizes, and becomes irritable ; the 
urine is foetid, mucous, and its stains are often retained. Catho- 
terism, opiates, laxatives, and regimen are the palliatives. 

INFLAMMATION OF THE BLADDER. 

This is usually a secondary affection, usually result ing from 
gonorrhoea, &c. There is pain in the perineum and sacrum ; mic- 



100 SURGERY. 

turition is frequent, with straining ; the urine is mixed with mucus 
or pus. 

Treatment. — Bleeding, leeches, hip-bath, opiate enemata, castor 
oil, &c. 

Chronic Inflammation. Catarrhiis Vesicm. — Maj result from 
the same causes as the acute form ; and also from over-distension of 
the bladder : it is attended with great irritability and incontinence 
of urine. The irritability and incontinence are sometimes the most 
prominent symptoms; and for these symptoms the injection of a 
solution of sulphate of morphia, or nitrate of silver, will be found 
most serviceable. 

ORCHITIS. 

Swelled Testicle is a common accompaniment of mumps. It is 
often the result of an injury; but, oftener, of gonorrhoea and its 
treatment : exercise, wet, and cold, often induce it. Sometimes it 
is termed hernia huonoralis. 

Symtptonis. — There is a great sense of weight, and the swelling 
constantly increases ; the skin becomes tense, red, and glistening; the 
pain is intense, often producing fever and vomiting. The cord is 
often swollen and painful. The epididymis is chiefly affected. The 
urethral discharge diminishes. 

Treatment. — Bleeding, in a plethoric habit; leeches, purgatives, 
tartar emetic, and opium; cold or warm lotions, according to the 
patient's feelings. Low diet and the recumbent position are essen- 
tial. The weight of the tumour must be sustained by a suspensory 
or handkerchief. After the acute symptoms have subsided, friction 
with mercurial ointment, astringent lotions, and compression by ad- 
hesive straps, will be useful. In discussing the hardness and swell- 
ing which generally remain, the iodide of potash has the best effect. 
Abscess may result, but it oftener results from chronic inflammation 
or sarcocele. 

Neuralgia of testes causes such severe pain that patients fre- 
quently apply to be castrated. The cause should be ascertained 
before treatment is commenced. 

HYDROCELE. 

This is a collection of serum in the tunica vaginalis testis ; com- 
mencing at the lower part of the scrotum, and gradually ascending. 
It is smooth on its surface, fluctuating. The testicle is situated at 
the posterior part of the sac, near the middle. It is to be distin- 
guished from hernia by its transparency and progress : there is no 
impulse upon coughing : it does not retire by recumbency. 

Treatment. — The palliative treatment consists of evacuation of 



ANEURISM. 101 

the serum by a trocar. The radical cure is performed by iDJecting 
stimulating fluids, such as port wine and water^ or solutions of zinc 
and iodine into the sac; or^ by introducing a seton. 

CIRSOCELE. 

Varicocele or cirsocele is a varicose condition of the veins of the 
cord. Some restrict the term varicocele to the enlargement of the 
veins of the scrotum. The causes are such as produce obstruction 
to the return of blood; constipation, corpulence, tight belts around 
the abdomen, and warm climate. The left side is more frequently 
affected than the right, because the left spermatic vein is more likely 
to be compressed by faeces in the sigmoid flexure, and because it is 
longer and not so direct in its course. The swelling is pyriform, 
and feels like a bunch of earth-worms. 

Treatment. — The disease may be palliated or cured by removing 
the causes, bathing the testicle in cold water constantly, and sup- 
porting it with a suspensory. The radical cure often requires an 
operation for obliteration of the veins, — such as the actual cautery, 
compression by sutures, wires, springs, &c. The scrotum may be 
diminished with advantage. 

ANEURISM. 

An aneurism is a pulsating sac, filled with blood, which commu- 
nicates with an artery. 

A TRUE ANEURISM. 

Is the result of disease, and the sac consists of one or more of 
the coats of the artery. The artery may be dilated, all the coats 
being entire, as is usually the case in the aorta; or, the internal 
and middle coats may be ruptured, and the sac is formed of the ex- 
ternal coat. The interior of the sac is lined by fibrin in a mem- 
branous form. 

FALSE ANEURISM. 

Is owing to a complete division of the arterial coats, either from 
a wound or external ulceration ; the sac is formed in the cellular 
tissue. 

DISSECTING ANEURISM. 

Is a sac formed by the infiltration of blood between the coats of 
an artery. This sac may communicate with an artery at several 
points. 

CIRCUMSCRIBED AND DIFFUSED ANEURISM. 

Are terms used to signify its limits; whether confined to a cyst, 
or extending by infiltration into the surrounding tissues. 

9^ 



102 SURGERY. 

Symptoms. — The most frequent form of Aneurism is the true cir- 
cumscrihed aneurism. The tumour, at first^ is small, gradually 
increasing, soft, and quite compressible, being only filled with fluid 
blood. It has a distinct pulsation from the beginning, synchro- 
nous with the heart's impulse, increased by pressure on the distal 
side, and diminished or arrested by pressure on the cardiac side. 
A peculiar thrill is imparted to the hand, which can be heard by 
application of the ear. At first the pain is slight, and merely 
owing to interference from the adjoining textures. By pressure 
upon the nerves a numbness is produced; pressure on the veins and 
lymphatics causes oedema, discoloration, and swelling. The strength 
of the part is much impaired, as the tumour enlarges ; the circula- 
tion in the extremity is weaker; the diminished volume of the 
main artery is compensated by enlargement of the side channels, 
the collateral circulation conveying the blood from the cardiac to 
the distal side of the tumour. The tumour gradually becomes larger 
by the separation of fibrin, is less compressible, and pulsates less 
distinctly. The clot thus filling up the sac, restrains its further 
dilatation by the force of the heart. Ultimately, it may become 
smaller by continued absorption. 

During the progress of an aneurism, adjacent parts are displaced, 
altered, and absorbed, even bone is rendered carious and absorbed 
by the constant pressure of the tumour. As the tumour enlarges, 
pain and numbness increase, and the general health fails. At length 
the tumour may burst, opening upon the skin or some important 
cavity, and prove fatal, either by hemorrhage, or by pressure on 
important parts, — as the trachea, oesophagus, &c., or by suppura- 
tion and hectic. 

The diagnosis from abscesses, glands, and solid tumours is impor- 
tant. An aneurism is soft and compressible from the first, and 
then becomes hard, whereas an abscess begins with induration and 
ends with softening. A tumour or other swelling, receiving an 
impulse from lying over the track of an artery, will no longer pul- 
sate when raised or held to one side. An aneurism expands coin- 
cidently with pulsation ; a solid tumour will not alter its volume 
by pressure either upon the distal or cardiac side. 

Causes. — The disease is more frequent in men than in women, 
and seldom occurs before puberty ; the predisposing cause may be 
said to be disease of the coats of the arteries ; the exciting causes 
are muscular exertion, mental emotion, and intemperance. 

Cure. — This may either be spontaneous or surgical — the sponta- 
neous being owing to pressure on the cardiac side of the tumour, 
occlusion of the aperture of communication, coagulation and absorp- 
tion, or by inflammation from sloughing of the cyst; this however 
is oftener the cause of death, than a means of cure. Medical treat- 
ment may mitigate the symptoms, such as bleeding, rigid diet, hori- 
zontal position, and cold and astringent applications. 



ANEURISM. 



lO:^ 



Compression is a means of cure^ which is slow and painful. 

The ligature is alone to be relied on. Previous to the time of 
Hunter^ the vessel was tied immediately above the tumour, and the 
sac opened. Hunter tied the artery at a distance from the sac, in a 
healthy part^ and allowed the sac and its contents to be absorbed ; 
this is the present mode of operating. Abernethy applied two liga- 
tures, and divided the artery between them. Brasdor's operation 
is directly the opposite to Hunter's, tying the artery immediately 
beyond the tumour. Wardrop modified this^ and tied the artery 
beyond the tumour and 

beyond its first bifur- Fig. 28. 

cation. The effect of ^--j ^^ -i ^^ 

a ligature is to arrest 
the blood and divide 
the internal and mid- 
dle coats; a coagulum 
or plug is formed up 
to the first branch, 
and lymph is effused 
from the cut edges of 
these coats, and also 
surrounds the ligature 
upon the exterior of 
the artery. The lymph 
in the artery above the 
ligature firmly consoli- 
dates the internal and 
middle coats ; and the 
cellular coat being 
compressed by the li- 
gature is subsequently 
destroyed, and thus the ligature is removed with its noose entire ; 
finally the portion of the artery which had been included in the 
ligature will be found converted into a small cord. 

The ligature should be round and small, or the coats will not be 
divided; inclusion of cellular tissue or a nerve will also prevent this 
division. 

Secondary hemorrhage may result from the application of an im- 
proper ligature, or its premature removal, and also from the artery 
being too much exposed, or in a diseased condition. 






ANEURISM OF THE AORTA. 



The arch of the aorta is especially liable to aneurism, producing 
difficulty of breathing, pain in the chest, and palpitation oi the 
heart, difficulty of swallowing, and troublesome cough, owing to its 
pressure upon the trachea, which is sometimes perforated : it should 



104 



SURGERY. 



not be mistaken for an enlargement of the bronchial glands, or col- 
lections of serum or pus. 

Aneurism of tJie abdominal aorta is usually situated just below 
the diaphragm^ producing pressure on the thoracic duct, also caries 
of the vertebra, dropsy, and by its rupture, death. 

Astley Cooper, James, and Murray have tied it without success ; 
it should be treated only by medical means. 



ANEURISM OF THE CAROTID. 

This occurs most frequently in labouring people ; it is situated at 
the angle of the jaw, near the bifurcation of the artery, and pro- 
duces difficulty of swallowing and breathing; it is to be carefully 

distinguished from glandu- 
Fig. 29. lar enlargement. It was first 

tied by Sir Astley Cooper in 
1805. The operation is thus 
performed : the patient being 
recumbent, with the head 
thrown back, and slightly 
turned to the opposite side, 
an incision three inches in 
length is made along the in- 
ner border of the sterno- 
mastoid muscle, through the 
integuments, platysma and 
superficial fascia, extending 
from near the angle of the 
jaw to the cricoid cartilage. 
The cross veins, descen- 
dens noni nerve, and the 
omo-hyoid muscle should be 
carefully pushed aside, the sheath opened, and the aneurismal needle 
introduced between the artery and the internal jugular vein, which 
is upon the outer side ; great care should also be taken not to include 
the par vagum nerve, which is included in the same sheath. 

AXILLARY ANEURISM. 

This tumour occupies the arm-pit and sometimes extends above 
the clavicle, producing pain and numbness in the arm. The opera- 
tion of tying the artery above the clavicle is thus performed : the 
patient is placed upon a high table and the shoulder forcibly de- 
pressed ; an incision (b. fig. 29), is made over the clavicle, through 
the skin and platysma myoides, reaching from the anterior edge of 
the trapezius to a little beyond the posterior edge of the mastoid ; 
the cervical fascia is then divided, the external jugular vein pushed 
aside, and the omo-hyoid disclosed; in the triangle formed by this 




ANEURISM. 



105 



muscle and the clavicle, we find the artery at the outer edge of the 
scalenus muscle^ passing over the first rib, with the nerves forming 
the brachial plexus above it, and the subclavian vein somewhat in 
front and below. Great caution should be used in exposing the ves- 
sel, on account of the varieties of the arterial distribution in the 
neck ; it should also be recollected the phrenic nerve descends upon 
the anterior face of the scalenus anticus muscle. 

The artery is tied also below the clavicle by making a semi- 
circular incision, with the convexity upwards, from near the sternal 
end of the clavicle towards the acromial, carefully avoiding the 
cephalic vein and acromial thoracic artery, which pass between the 
outer edge of the pectoralis major muscle and the deltoid. After 
dividing the skin, superficial fascia, and pectoralis major, the pecto- 
ralis minor will be exposed, between the upper edge of which and 
the lower edge of the subclavian muscle, the artery will be found 
deeply imbedded in cellular tissue and fat ; the vein is in front, and 
the axillary plexus of nerves surround the artery. 

The arteria innominata has been tied, but without much success 
where the tumour is large. The patient lying on his back, with 
his shoulders raised, and the head thrown back, an incision two inches 
in length is made on the inner side of the sterno-cleido-mastoid, 
reaching to the sternum; another incision is made just above the 
clavicle and through the sterno-mastoid : thus a flap can be turned 
up ; the sterno-thyroid and sterno-hyoid are then to be divided on a 
director, and the deep fascia exposed ; cautiously opening this fascia, 
the vein is to be pushed aside, avoiding the par vagum, recurrent, 
and cardiac nerves. 

BRACHIAL ANEURISM. 

This is usually the result of violence, and is very often a false 
aneurism ; the tumour is in the bend of the arm, and inconveniences 
its mobility. 

Fio;. 30. 




The brachial or humeral artery is tied by making an incision on 
the inner edge of the biceps flexor muscle, of two inches in length, 
about the middle of the arm. The median nerve will be found first, 



106 



SURGERY. 



lying close to tlie artery ; this and the veins are to be carefully se- 
parated. It must be borne in mind^ that the artery may bifurcate 
as high as the axilla. If it be necessary to tie the artery in the 
upper portion of the arm, an incision is to be made over the pul- 
sating vessel, and it will be found on the inner edge of the coraco- 
brachialis muscle ; the nerves and veins are to be carefully avoided. 
Deligation of the radial and ulnar arteries is seldom required 
except for wounds. Often wounds in the palm of the hand require 
the tying of the humeral artery. The radial may be exposed in 
the upper part of the forearm, by an incision through the skin and 
superficial fascia. By separating the supinator longus muscle from 
the pronator teres, the artery will be found as it passes over the 
tendon of the pronator. In the lower part of the forearm the radial 
may be readily exposed by making an incision through the skin and 
fascia on the outer border of the flexor carpi radialis; and the idnar 
by an incision on the radial side of the flexor carpi ulnaris muscle. 



INGUINAL ANEURISM. 



This is a pulsating tumour in the groin, not to be mistaken for a 

bubo, hernia, &c. The ex- 
Fig. 31. ternal iliac is tied by making 
an incision (a, Fig. 31), 
about 3 J inches in length, 
commencing on a level with 
the anterior superior spinous 
process, and about an inch 
distant from it; and con- 
tinued nearly parallel with 
Poupart's ligament, to a point 
1 inch above, and IJ inches 
to the outside of the pubes. 
Carefully cutting through 
the skin, superficial fascia, 
tendon of the external ob- 
lique, internal oblique, and 
transversalis muscles, the 
fascia transversalis will be 
exposed, with some danger 
of wounding the epigastric 
artery. This fascia should 
be scratched through, and 
the peritoneum pushed aside, 
and held out of the way by an assistant with a spatula : the artery 
will be detected by its pulsation on the inner border of the psoas 
muscle, the vein being on its inner side. The operation for tying 
the internal iliac or the common iliac is made by making an in- 




POPLITEAL ANEURISM. 



107 



cision h. The letter c shows the incision of Sir Astley Cooper when 
he tied the aorta. 



POPLITEAL A N E U Pv, I S M. 



This is of frequent occurrence, and 
occupies the space between the hamstrings 
behind the knee, causing pain, numbness 
and swelling of the leg, disease of the 
joint, &c. 

The operation is to tie the femoral ar- 
tery. The patient being properly placed, 
the sartorius muscle is rendered prominent 
by raising and adducting the thigh. An 
incision of two or three inches in length is 
made upon the inner side of the sartorius 
muscle, in the upper part of the thigh, 
according to Scarpa, where the artery is 
superficial. The saphena vein is to be re- 
garded in the dissection of the superficial 
fascia. After opening the sheath, care 
must be taken not to injure the vein, nor 
to include the saphenus nerve. Hunter^ s 
operation is somewhat below, and in its 
performance the sartorius must be divided 
or pushed aside. — The anterior tibial ar- 
tery may be tied in several places : at the 
upper part of the leg, by a free incision, so 
as to get between the tibialis anticus and 
extensor communis digito- 
rum. After the division 
of the superficial fascia, a 
proper allowance should be 
made for the breadth of 
the tibialis anticus, in order 
to strike the line of division 
upon the dense fascia be- 
tween the two muscles. The 
artery will be found at the 
bottom of this space, lying 
on the interosseous mem- 
brane. 

At the lower part of the 
leg a less incision is neces- 
sary, the vessel being more 
superficial. The wound is 
made on the tibial side of 




Fig. 33. 




108 



SURGERY. 



the extensor proprius poUicis. The venae comites and anterior tibial 
nerve are to be avoided. 

On the instep the artery may be secured by making an incision 
on the fibular side of the tendon of the extensor proprius pollicis. 

The posterior tibial may be readily tied near the middle of 
the leg, upon the inner side ; divide the skin, superficial fascia, cru- 
ral fascia, and some 
Fig. 34. fibres of the soleus, 

and the leg being flex- 
ed, the triceps surse 
can be pushed aside 
^jh^'^'"' \.\ sufficiently to expose 

\! J Mil II '''■■'■■■-■ ■' ''A the sheath of the ves- 

sels; the artery is to 
be carefully excluded 
from the veins and 




nerve. 

At 



the 



ankle the 
operation is simple. 
A semilunar incision 
is made, posterior to 
the internal malleolus, 
through the skin and 
superficial fascia, and 



a thick aponeurosis ; this exposes the sheath of the vessels. 
veins and nerve are to be excluded. 



The 



VARICOSE ANEURISM. 

This is usually the result of a wound, and occurs most frequently 
in the elbow after bleeding. An opening remains both in the artery 
and in the vein, and a cyst is formed with this double communication. 

The arterial blood en- 
Fig. 35. ters the vein, and pro- 
duces greater or less 
distension of it. This 
enlargement of the 
vein is recognised by 
a peculiar thrill, re- 
sembling the purr of 
a cat : it may exist 
"^ ' ' for some time with- 
out any inconvenience, and is to be removed by tying the artery 
above and below the sac, and oftentimes it is necessary to tie the 
vein. 

Aneurismal varix is another variety, occurring under the same 
circumstances, at the bend of the arm. The vein and artery com- 





AMPUTATION. 109 

niLinicate, as in the former, but without any cyst interposed ; the 

swelling is less, but more diffused, and varicose distension of the 

veins is very great. The 

limb below the tumour Fig. 36. 

is imperfectly supplied 

with arterial blood, and, 

consequently, cold, numb 

and vitally weak, and 

also liable to congestion 

and oedema. It is to be 

treated by pressure, so as to repress the swelling, and moderate 

the sanguineous mixture : this will palliate the symptoms, and 

permit the use of the limb. A permanent cure can only be effected 

by tying the artery above and below the aperture of communication. 

Aneurism hy anastomosis presents itself in various forms : 1. 
Capillaries of a portion of integument may be equally and perma- 
nently dilated, producing discoloration and slight elevation of the 
part. This is one form of nsevus, or congenital mark, which is 
attended with no danger, and may be considered as a deformity 
rather than as a disease. 2d. The structure may consist chiefly of 
dilated veins fed by arterial branches. This structure is not found 
in the true skin, but in the adjacent cellular tissue; or it may be 
submucous, as is exemplified by one variety of hemorrhoid. 3d. 
The swelling may consist chiefly of dilated and active arteries, 
supplied with large tortuous veins, which are mere conduits from 
the tumour ; the tumour is erectile, and varies in bulk and tension, 
according to the state of the circulation. It often grows rapidly, 
and brings life into imminent peril. 

Its removal may require the knife, excision, or compression. 

AMPUTATION. 

Amputation is not to be resorted to until all other means of cure 
have failed. In cases of 2;ano;rene, laro;e malio-nant tumours in vol v- 
ing a bone or a joint, diseases of the joints causing hectic and 
threatening life, and in case of recent injury, where reparation is im- 
possible, then amputation must be performed. 

In case of injury, amputation is either primary or secondary : 

Primary ; when performed immediately after the patient has re- 
covered from the shock of the injury, and before febrile excitement. 

Secondary ; after suppuration has commenced, and perhaps 
sloughing. Secondary amputations are also performed for diseases 
of the bones or joints. 

Primary amputations are to be performed when it is impossible to 
save the injured limb. In military practice, limbs are amputated for 
injuries, which a surgeon might attempt to save in civil practice ; there 

10 



110 SURGERY. 

being less opportunity for treatment^ and less favourable opportunity 
for secondary amputation. 

Instruments and Dressings. — Amputating knives^ catlins saw^ 
tourniquets, scalpels, tenacula, forceps, needles, ligatures, sponges, 
bone-nippers, compresses, rollers, retractors, lint spread with cerate, 
charpie, adhesive strips, and warm water. 

AMPUTATION OF THE THIGH. 

The patient having been brought to the edge of the bed, his back 
is supported by pillows, and his hands held by assistants. The 
tourniquet is applied over the superficial portion of the artery, about 
three inches below the groin, so as to interrupt the circulation of 
blood in the limb. This, like other amputations, may be performed 
in two ways, either by the circular incision or by the flap operation. 

CIRCULAB, INCISION. 

The surgeon stands so that he may use his left hand to grasp the 
part which he is to amputate, the leg being firmly supported, in a 
horizontal position, by an assistant; the surgeon then carries the 
amputating knife under the limb, and with one complete sweep round 
the limb, divides the skin, fat, and fascia. A scalpel is then used 
to dissect the integuments from the muscles, in order that they may 
be turned up, for two inches, in the same way that one would turn 
up the cuff of a coat. Vf ith the amputating knife, the muscles are 
now cut through down to the bone, the edge of the knife being in- 
clined upwards, in order that the stump may present somewhat of a 
conoidal cavity; the muscles are to be slightly separated from the 
bone, and a retractor applied to pull them upwards. In using the 
saw, the heel should first be applied on the bone, and a groove 
made; by steady strokes the bone is divided, care being taken to 
prevent splintering and roughness : in case there should be any, it 
may be removed bj' bone-nippers. The large vessels can now be tied, 
and the stump sponged with warm water, in order to detect orifices 
of smaller ones. After hemorrhage is completely arrested, and the 
tourniquet somewhat loosened, the end of the bone is to be covered 
by the muscles and skin, so as to form a rounded stump ; the edges 
are to be retained by adhesive strips, and the ligatures brought out 
at the corners of the wound. The stump is nov/ covered by lint 
spread with cerate, and over this a thin pledget of charpie or tow ; 
the whole is supported and covered by a roller, which should 
be carried once or twice around the patient's pelvis. Having been 
carefully placed in bed, the stump is supported upon a pillow, and 
secured to it by pins ; over the stump is placed a frame, to take off 
the weight of the bedclothes. During the winter the dressings may 
remain on seven or eight days ; in summer only two or three ; a 



AMPUTATION AT THE IIIP-JOINT. 



Ill 



poultice previously applied may facilitate their removal. The after- 
dressings may be repeated once in forty-eight hours. About the tenth 
day the ligatures may come away^ and generally, the wound is healed 
in three or four weeks. Some suppose that the stump may be better 
covered by flap operation^ especially should the integument be 
thin. 

FLAP OPERATION. 

The original plan of Vermale was, to introduce a knife perpen- 
dicularly to the anterior surface of the thigh, and to cut a lateral 

Fig. 37. 




flap on either side. Liston and others prefer an anterior and pos- 
terior flap, which prevent the end of the bone rising at the upper 
angle of the wound, and protruding forwards. These are made by in- 
serting the knife by the side of the thigh, as in Fig. 37, instead of 
upon its anterior surface. The objections to the flap operation are 
the injuries to vessels and nerves, by transfixion and oblique divi- 
sion. 



AMPUTATION AT THE HIP JOINT. 

This operation is rarely necessary, and is always severe and dan- 
gerous; it should never be performed for disease of the joint. The 
patient is to be placed on a table, with his pelvis projecting from 
the edge. The artery is compressed by an assistant, who must be 
ready to thrust his fingers in the wound formed during the forma- 
tion of the anterior flap, so that he can grasp the end of the vessel, 
as soon as it is cut. The knife is entered about middle way between 
the trochanter major and the anterior superior spinous process of 



112 



SURGERY. 



the ilium. By cutting downwards, the anterior flap is formed. The 
head of the bone is then disarticuhited, and the blade of the knife 
being then placed behind the bone, is carried downwards and back- 
Fig. 38. 




wards, so as to form a posterior flap ; the vessels are to be rapidly 
secured, and the flap managed as in all other flap operations. By 
some the formation of a lateral flap is preferred. Very often the 
selection of the flap will depend upon the character of the wound 
which may render the operation necessary. 



AMPUTATION OF THE LEG. 



The length of the stump will, in some measure, depend upon the 
kind of artificial limb to be used. If the patient is to rest upon his 
knee, the stump should be short, in order to be bent at right angles. 



CIRCIILAE- METHOD. 



The tourniquet having been applied, the integuments are to be 
divided, dissected up, and turned back for two inches ; the muscles 
are to be divided, down to the bone, by a second circular incision. 
Then a catlin is to be passed between the bones, so as to divide the 
interosseous ligament and muscles ; a three-tailed retractor is then to 
be applied, and the bones sawn through together. If the spine of 
the tibia projects much, it can be removed by a fine saw, or bone- 
nippers. The vessels are to be secured, and the stump treated as 
in amputation of the thigh, the integuments being brought together 
in a straio'ht line. 



AMPUTATION OF THE FOOT. 



113 



FLAP OPERATION. 



This is generally preferred, and is thus performed. The surgeon 
first places the heel of the knife on the side of the limb; farthest 

Fig. 39. 




from him, and draws it across the front of the limb, in a semicir- 
cular direction, making a semilunar flap. When its point has ar- 
rived at the opposite side, it is at once made to transfix the limb, 
and then the larger and posterior flap is cut. In transfixing the 
limb, care must be taken not to pass the knife between the bones. 
This amputation may also be performed near the ankle ; but, in this 
instance, it will be necessary to shorten the tendo Achillis after the 
flap is made. The leg should not be amputated nearer the knee 
than the tuberosity of the tibia, or the joint will be opened, and 
inflammation result. Hence amputation at the hnee is rarely per- 
formed, although disarticulation may be readily performed with a 
large scalpel. In this operation the patella should be allowed to 
remain. 



AMPUTATION OF THE FOOT. 

The foot is amputated at two places. 



CHOPART'S OPERATION. 



A flap is made from the upper part of the instep, and the disarti- 
culation commenced immediately behind the tuberosity of the sca- 
phoid bone. The bistoury is passed between the scaphoid and head 
of the astragalus, and then between the cuboid and os calcis : an in- 
ferior flap is then made from the sole of the foot. 

10^ 



114 



SURGERY. 



KEY'S OPERATION. 



The disarticulation is comiuenced immediately behind the tube- 
rosity of the fifth metatarsal bone; separating the fifth and fourth 
metatarsal bones from the cuboid, the third and second from the 
external and middle cuneiform bones. The internal cuneiform is 

Fig. 40. 




either removed or sawed through. The superior flap is made before 
the disarticulation, and the inferior one subsequently. 



AMPUTATION OF THE GREAT TOE. 

The most convenient mode of removing this toe is by incisions 
represented by dotted lines in this figure. Commencing upon the 

inner side of the metatarsal bone, and 
[Fig. 41. running round the joint obliquely, 

taking care not to wound the anterior 
tibial artery. The flap is made from 
the outer side of the toe. It will 
cover the head of the metatarsal bone 
more perfectly, and can be more rea- 
dily retained in its position than any 
other. 

AMPUTATION AT THE SHOULDER 
JOINT. 

Hemorrhage is to be restrained by 
pressure with the fingers, or the handle 
of a key well padded, upon the subcla- 
vian artery, as it passes over the first 
rib. The flaps may be cut by trans- 
fixion, or in the manner represented 




AMPUTATION OF THE ARM. 



115 



in Fig. 42. The external flap should be made first, out of the del- 
toid, and then the head of the bone disarticulated. The internal 
flap is smaller, and made last^ in order that the vessel may be se- 
cured immediately upon 



the limb being severed. 
In some instances it 
may be necessary to re- 
move the whole of the 
scapula, and one half of 
the clavicle. The ex- 
tent and character of 
the injury must often 
determine the shape of 
the flaps. 

AMPUTATION OF THE 
ARM. 

The circular opera- 
tion is most frequently 
performed. The artery 
is compressed by a tour- 
niquet or the fingers, 
and the skin drawn firm- 
ly back. One circular 
incision will divide the 
skin and fascia; another 
will divide the muscles. 



Fig. 42. 




If the knife is held so that the edge is 
Fig. 43. 




116 



SURGERY. 



directed slightly toward the shoulder, the end of the bone will be 
found in a conical cavity, and can be well covered by the muscles 
and skin. 

The flap operation is sometimes performed. The arm being trans- 
fixed, the anterior flap is made first ; the vessels are divided when 
the posterior flap is cut. 

Amputation at the elbow is performed by making a single flap 
from the muscles and skin in front of the joint. The head of the 



radius is disarticulated first : 
let the olecranon remain. 



the ulna is then to be sawed, so as to 



AMPUTATION OF THE FOREARM. 

The tourniquet is applied to the brachial artery as in other opera- 
tions upon this extremity. 

Two flaps are formed, one on the dorsal, the other on the palmar 

aspect. These are best 



Eig. 44. 



and 




made by transfixing 
cutting outwards. 

The amputation should 
be performed as near the 
wrist as circumstances will 
admit of; although below 
the middle it is not easy to 
obtain sufficiency of flaps. 
But, the general rule is, to 
remove as little as possible 
from the organs of prehen- 
sion ; and operations are 
attended with less risk to 
life the farther they are 
removed from the trunk. 



AMPUTATION AT THE 
WRIST. 



The disarticulation of the 
radio-carpal joint is readily 
efiected by commencing at the styloid process of the radius. A dorsal 
and palmar flap is made of the skin. The pisiform bone is to be 
allowed to remain. 



AMPUTATION OF THE FINGERS. 



The hemorrhage may be controlled by an assistant's grasping the 
wrist tightly. The finger may be amputated at a joint or in the 
middle of a phalanx, though it is important to save as much as 
possible. The operation may be circular, or with a flap, which 
should be made from the palmar aspect of the finger. 



ENCEPHALOID. 117 



C A N C E K. 



Malignant diseases change the original structure of the part, 
transform or destroy the surrounding tissues, travel in the course of 
the lymphatics, contaminate the nearest glands, affect several organs 
in the same individual, and, if mechanically removed, reappear in 
or near the cicatrix. 

Malignant growths contain granules or nucleated cells, imbedded 
in a fibro-cellular tissue. They are composed almost entirely of 
albumen. Their development is dependent upon perverted nutrition. 
The causes are perpetual local irritation, and a morbid state of the 
constitution, which may be hereditary. In the ordinary sense of 
the word they are not contagious; but cancer-cells injected into the 
blood of a dog, produce malignant disease of the lungs. 

Cancer is a term applied to several kinds of malignant disease; 
and under this term are included several morbid growths, eiicepjJia- 
loid, schirrJius, and colloid^ whose physical characters are so various 
that they have formerly been considered as separate aff'ections. 

ENCEPHALOID. 

This is often called Medullary Sarcoma, Soft Cancer, and Cepha- 
loma. The word Encephaloid is preferred because it denotes the 
resemblance which the morbid product bears to the brain in colour, 
texture, and consistence. The tumour is highly vascular, which in 
some measure accounts for the rapidity of growth and the great 
size to which tumours of this kind attain. 

The skin investing the tumour is pale, with numerous veins 
coursing beneath it. At first it is moveable on the tumour, but 
afterwards ultimately incorporated therewith. The growth is not 
circumscribed and moveable, but fixed and diffused into the sur- 
rounding parts. To the touch a sense of great elasticity is imparted, 
different from the fluctuation of chronic abscess, and different also 
from the semi-fluctuation which the fatty tumour exhibits, yet some- 
what resembling both. 

Pain is almost always considerable, often severe and shooting. 
In some cases it is at first absent; and then the tumour is usually 
of slow growth, but when it enlarges in the ordinary manner, as it 
soon does, the pain becomes developed, and continues. The patient 
is obviously cachectic, and bears on his countenance a plain token 
of a formidable disease ; the features are shrunken and anxious, the 
hue is sallow, emaciation is begun, the functions of animal life are 
all disturbed, and hectic is setting in. It attacks more frequently 
young persons, and may occur in any texture, though most com- 
monly it aff*ects the orbit, testicle, mamma, joints, internal viscera, 
and lymphatic ganglia. 

The section of an encephaloid mass, when fully developed, pre- 
sents the appearance of an almost homogeneous matter, of an opaque 



118 SURGERY. 

milky colour, ordinarily dotted with spots of pinkish hue, varying 
in different specimens in number, size, and shape. In consistence 
it closely resembles the healthy brain of an adult, and may be 
broken up between the fingers with about the same facility as the 
substance of that organ ; if torn through, the lacerated surface pre- 
sents a coarsely-granular aspect. Sometimes it is divided into 
lobules by fibrous bands intersecting the mass ; and in tumours of 
considerable duration, softening will occur, and the skin will give 
way. So long as the tumour is invested by the integument, it is 
said to be occult ; when the skin has given way, and the morbid 
structure consequently becomes exposed, it is said to be in the ojjen 
state. During the softening of encephaloid, the vessels become 
opened, the effused blood more readily enters the soft tissue, and 
mixes with it, than in the harder sorts of cancer; the whole mass 
assumes a sanguineous appearance, and in this way encephaloid 
merges into Fungus Hsematocles. Black granular pigment may 
likewise enter into the composition of encephaloid, forming Mela- 
nosis. 

There are certain forms of cancer-cells which are characteristic 
of encephaloid, for instance, parent-cells with young cells in their 
interior, cells with numerous cytoblasts, and the irregular caudate 
and ramifying cells. Of all forms of cancer, encephaloid runs the 
quickest course, is the most malignant, and causes death in much 
the shortest time. 

SCHIRRUS. 

Schirrus usually forms a roundish tumour with a more or less 
nodulated surface. Its consistence is generally very firm ; the 
tumoar in this respect resembling cartilage or even stone; this 
hardness depends on its fibrous structure, and varies with the 
toughness, compactness, and amorphous character of the fibres. Its 
nodules, in cases where the tumour is superficial, are frequently ob- 
served on the application of the hand, to be of a lower temperature 
than the surrounding parts ; this is probably dependent on the li- 
mited supply of blood to the part. It is much less vascular, and 
of much slower growth than encephaloid ; softening does not take 
place as rapidly, and, until this occurs, the life of the patient is 
comparatively safe. A section of one of these tumours sometimes 
appears of a bluish-white or milky colour, resembling other fibrous 
tumours; sometimes it presents a more opaque appearance, and is 
tinged with yellow or red; when softening has commenced a caseous 
appearance is presented. As a general rule, schirrus is intimately 
blended with the surrounding parts, not being enclosed in a capsule, 
or presenting a definite border. Schirrus has a constant tendency 
to transition into encephaloid or colloid. The mutual relations be- 
tween the fibres and the cancer-cells vary extremely in schirrus ; so 



CLUB-FOOT. 119 

much so, that it is frequently impossible to distinguish some parts 
of the tumour from encephaloid, and others from fibrous tumour. 
The cells are small, round or oval, and granular. Schirrus contains 
a viscid fluid, which, when it occurs in excess, forms the transition 
to gelatinous cancer. The pain is at first slight, and gradually in- 
creases as the disease progresses. It occurs more frequently in 
women^ and attacks the mammary gland, generally after middle 
life. 

COLLOID. 

This variety of cancer consists of a jelly-like matter, enclosed in 
cellular cavities, varying from the size of a pin's head to that of an 
egg'; the walls of these cavities are composed of fibrous tissue, such 
as occurs in schirrus, and the jelly is colourless and transparent, 
containing pale cells, which differ from true cancer-cells, being, 
generally speaking, larger, more delicate, and the walls not being 
so thick. No true softening or suppuration occurs in this form of 
cancer; in the intestinal canal, where it is most frequent, the sur- 
rounding tissues become gradually infiltrated with this jelly; stric- 
tures are thus formed in the gut, and the contents of the canal 
being pressed on by the soft gelatinous mass, give rise to perforation 
of the walls. Hence gelatinous cancer is in some degree different 
in its progress from the other forms of carcinoma. 

Treatment. — The treatment of any form of cancer will, in a great 
measure, depend upon the development of the disease. A small 
tumour of a schirrous form m.ay be extirpated, with some chance of 
success, though not with certainty as to its non-reappearance. When 
the cancer is open and ulcerated, the treatment should be directed 
to the constitution, which will, sooner or later, sink with symptoms 
of hectic. 

CLUB-FOOT. 

This deformity may be either congenital or acquired. The con- 
genital form is dependent upon some disturbance of the cerebro- 
spinal system, that produces irregular contraction of the muscles, 
by which antagonism is destroyed. 

The accidental causes by which it may be acquired, are injuries 
and diseases of the foot or ankle, convulsions, scarlet fever, cica- 
trices, rickets, &c. 

The principal varieties are three : — 1. Talipes Varus, in which 
the foot is turned inward, as in Fig. 45, and rests upon its outer 
edge. There are various grades and modifications of varus. The 
foot is not dislocated, but the bones deviate from their normal di- 
rection, and their articular surfaces are partially separated. The 
astragalus is least altered in position. The ligaments on the outer 
side are lengthened, and those on the inner are shortened. The ton- 



120 



SURGERY. 



dons of the tibialis anticus and posticus, and the tendo Achillis, are 
most contracted ; the peronei muscles are relaxed. 

Fig. 45. 




2. Talipes Valgus. The foot is everted^ and rests on its inner 
edge. It is a rare form of club-foot. The ligaments on the inner 
side are relaxed. The peronei muscles are contracted^ and the tibi- 
alis anticus and posticus elongated. 

3. Talipes Equinus. — In this variety the foot rests upon the 
ball, or upon the toes. After a person has walked for a number of 
years the deformity is increased, as is represented in the drawing 
(Fig. 46). The shortening is due to contraction of the triceps ten- 
don^ and thickening of the plantar fascia. 



Fig. 46. 




There are two other varieties ; 
one in which the toes are drawn up 
by contraction of the extensors, and 
the patient walks upon the heel; 
and the other when the dorsum or 
instep comes in contact with the 
ground. Besides which there may 
be various complications of the 
above. 

The prognosis will depend upon 
the degree of contraction, the va- 
riety of the deformity, the condition 
of the bones, and the age of the 
patient. 

Treatment. — Many cases of con- 
genital club foot may be rectified 
by constantly wearing a proper 
apparatus, especially if the treat- 
ment be commenced in early child- 
hood ; but in confirmed cases it is 



DISEASES OF THE EYELIDS. 121 

better to resort at once to Stromeyer's operation of division of the 
tendons. The operation is thus performed. 

The tendon is put on the stretchy and a narrow, sharp-pointed 
knife is thrust through the skin externally to the tendon ; then the 
edge is directed towards the tendon and the knife withdrawn, 
cutting the tendon as it escapes. 

The operation will facilitate the cure in most cases, provided the 
subsequent treatment be effectually maintained ; and this depends 
as much upon the fidelity of the parent or nurse in the constant 
application of the apparatus as upon the skill of the surgeon. 

There may be said to be little or no danger resulting from the 
operation. 

Various foot-boards and shoes are to be worn, by which the de- 
formity is gradually and permanently overcome. 

The most favourable period for the operation is between six and 
eighteen months. G-reat care is required not to produce excoriation 
and ulceration of the skin in a young child. Oftentimes it is better 
to remove the apparatus entirely than run the risk of producing 
fever or convulsions. 

AFFECTIONS OF THE EYE. 

DISEASES OF THE EYELIDS. 
HOKDEOLUM, OR STYE, 

Is a small painful boil, in the cellular tissue upon the edge of the 
eyelids. Some suppose that it originates in the sebaceous glands at 
the roots of the cilia, or in the follicles of the cilise. A scrofulous 
constitution predisposes to the occurrence of them. 

Treatment. — Those who are liable to them should pay attention 
to the condition of the stomach and bowels. Cold applications and 
nitrate of silver may arrest it ; but generally it suppurates, requiring 
poulticing and puncturing. 

OPHTHALMIA TARSI. 

This is a chronic inflammation of the edges of the eyelids, occur- 
ring most frequently in scrofulous children. The edges are swollen 
and red ; the eyelashes loaded with Meibomian secretion ; and ^e 
lids are glued together in the morning. There is itching, smarting, 
and a sensation of stiffness. When the disease is of long standing, 
the eyelashes fall out, and the new ones are misdirected, and irritate 
the conjunctiva. In adults it may be the result of catarrhal ophthal- 
mia, or be produced by cold and damp air, or by intemperance. In 
children it may be the result of eruptive diseases. 

Treatment. — Alteratives, laxatives, and tonics. The state of the 
skin requires attention. Fomentation will remove the incrustations 

11 



I 



122 SURGERY. 

Loose and misdirected eyelashes are to be removed. An ointment 
composed of gr. x. of red precip. and an ounce of cerate is to be 
carefully applied at nigbt ; and in the morning the lids are to be 
bathed with tepid water, and not separated forcibly. In inveterate 
cases, sulphate of copper and nitrate of silver may be applied to the 
edges, in case the conjunctiva is thickened; and blisters maybe 
placed behind the ears. 

ENTROPION 

Is a permanent inversion of the eyelid, and often results from 
tarsal ophthalmia, from a relaxation of the integuments of the eye- 
lid and spasmodic contraction of orbicularis palpebrarum muscle 
when long continued, or by contraction of the conjunctiva; constant 
pain and irritation follow from the cilise rubbing against the ball. 
It is to be distinguished from trichiasis^ in which the cili^ are in- 
verted, and irritate the ball whilst the lids remain in their natural 
position. 

The only treatment which can be of permanent benefit, is the ex- 
cision of a fold of skin, from near the edge of the eyelid ; but this is 
only applicable in certain cases where the cause is relaxation of the 
skin. 

ECTROPION 

Is an eversion of the eyelid, caused often by a thickening of the 
conjunctiva from long inflammation, or from cicatrices upon the 
skin of the eyelid, resulting from a blow or burn. This is to be 
cured by bringing the conjunctiva to a healthy condition, by the 
application of nitrate of silver or sulphate of copper. Should these 
remedies fail, a portion of the conjunctiva is to be excised, or a por- 
tion of new skin to be substituted for the cicatrix. 



Is a falling of the upper eyelid, from a palsy of the third nerve, 
or from an injury of the levator palpebrse superioris muscle. It is 
often connected with congestion of the head, and may be a precursor 
of apoplexy, and should be treated by bleeding, purgatives, mercury, 
and blisters. If persistent, it may be obviated by removing a fold of 
the skin from the upper eyelid. 

DISEASES OF THE LACHRYMAL APPARATUS. 
XEROPHTHALMIA 

Is a dryness of the eye, arising either from a want of secretion of 
the conjunctiva, or, as some suppose, from a deficiency of tears. 
It is to be remedied by frequently bathing the eye with mucilage. 



FISTULA LACHRYMALIS. 



128 



EPIPHORA 



Is a superabundance of tears, so that they run over the cheeks : it 
should be distinguished from htUllcidhi'mladhvyniarura^ which .is an 
overflow in consequence of an obstruction of the channels that convey 
them to the nose. It arises frequently from scrofulous inflammation ; 
or from the action of chemical or mechanical agents, cold winds 



acrid vapours, &c. 
cause. 



The treatment will, of course, vary with the 



OBSTRUCTION OF THE LACHRY3IAL DUCT 

Is known by the overflow of the tears, the dryness of the nostril, 
distension of the sac, and the formation of a small tumour. It often 
leads to inflammation and abscess. In other instances, it results io 
thickening of the tubes and duct, which may be much benefitted bj 
the use of probes. The puncta and canaliculi may be dilated sufll- 
ciently to admit a probe of the same thickness as the ordinary style. 



VISTULA LACHRYMALIS 



Fig. 47. 



Is an aperture at the inner corner 
of the eye, the result of a bursting 
of an abscess caused \j obstruction. 
The inflammation of the sac is to 
be treated by leeches and cold ap- 
plications. If suppuration cannot 
be obviated, the tumour is to be 
opened as soon as it has become 
soft and fluctuating. The opening 
should be made parallel to the 
margin of the orbit, and below the 
tendon of the orbicularis. The 
sac should then be fomented and 
thoroughly cleansed, and after a 
few days, should any doubt exist 
with reference to the perviousness of the tubes aud sac, an expl 
tion is to be made by probes. 

Should the obstruction be firm, the 
opening into the sac will remain fis- 
tulous, and then a style must be intro- 
duced. The object of the style is to 
dilate the strictured portion of the sac. 
The form and size is represented in the 
cut. They are usually made of lead, 
silver, or gold, and sometimes of catgut. 
Some have thought best that there 
should be a groove on the style, or 
that it should be hollow, but this is unnecessary ; 




Fiff. 



Fio;. 49. 



^ 



for al- 



though the style may occupy the whole of the calibre of the 



124 SURGERY. 

duct when first introduced^ the tears gradually widen it and flow 
readily by the side of it. 

DISEASES OF THE CONJUNCTIVA. 

ACUTE CONJUNCTIVITIS. 

Spnj)toms. — Smarting, heat, stiffness, with a feeling as if dust 
had got into the eye. Subsequently the secretion of mucus in- 
creases; which becomes puriform. The vessels of the conjunctiva 
are turgid and numerous, giving it a bright-red appearance. There 
is slight intolerance of light and increased flow of tears. 

Causes. — Cold or damp, bad condition of stomach, or local irrita- 
tion. 

Treatment. — A dose of calomel followed by a saline cathartic; 
leeches, cold applications, moderately dark room, and a solution of 
nitrate of silver. The disease may become chronic; when blisters 
behind the ear, and astringent applications to the eye will be 
useful. 

PUHULENT CONJUNCTIVITIS. 

This, and Egyptian oplitliahnia^ are more severe forms of the 
same affection, and are infective. The most severe form of in- 
flammation of the conjunctiva is gonorrlio&al ophthalmia ; in this 
variety the eye is often lost. The treatment must be early and 
active. 

SCROrULOUS CONJUNCTIVITIS. 

Symptoms. — Extreme intolerance of light, the eyelids are spas- 
modically contracted, the head is turned away from the light, there 
is no general vascularity of the conjunctiva, but a few vessels run- 
ning towards the cornea, terminate in phlyctenulse, or pustules on 
the cornea. This disease is most obstinate and liable to perpetual 
recurrence, often resulting in ulceration of the cornea, or opacity 
from effusion of lymph between its layers. 

Treatment. — Local applications are of no avail unless the general 
health be improved. A dose of calomel and rhubarb should be fol^ 
lowed by tonics and alkalies, and other general remedies for scro- 
fula, such as quinine and salt baths. The nitrate of silver exer- 
cises a more sedative and antiphlogistic influence than any other 
local remedy. 

GRANULAR CONJUNCTIVITIS 

Is a thick, rough, fleshy state of the palpebral conjunctiva, de- 
pendent upon long-continued inflammation; it causes great pain and 
disturbance to the motion of the eye, and if it continues will render 



IRITIS. 125 

the cornea opaque by its friction. These granulations are dependent 
upon a hypertrophy of the papillae of the palpebral conjunctiva^ and 
a thickening of their epithelium. 

Treatment. — If the granulations are long, they may be removed 
by the knife or scissors ] ordinarily they can be cured by scarifica- 
tion, lunar caustic, and sulphate of copper ; at the same time the 
general health must be attended to, and blisters may be applied be- 
hind the ears. 

ULCER OF THE CORNEA. 

This most frequently occurs as a result of conjunctivitis, especi- 
ally of the scrofulous form, but may arise from mechanical injury* 
it often penetrates the cornea and leaves an opaque cicatrix. When 
the ulcer is liealthy^ its surface is somewhat opaque, owing to the 
effusion of lymph ; when inflamed^ vessels will be found approach- 
ing it ; when indolent^ it is clear, and transparent, appearing as if 
a small piece had been cut out of the cornea. The nitrate of silver 
is the best application to the inflamed and indolent ulcer of the 
cornea. If the acetate of lead be used, a white precipitate is 
formed, which is liable to become fixed in the cicatrix as a dead- 
white spot. 

SCLEROTITIS. 

This disease is often called rheumatic ophthalmia. It is known 
by redness of the sclerotica, slight intolerance of light, severe aching 
pain of the eye and the bone surrounding it, which is aggravated at 
night. It is distinguished from conjunctivitis by the character of 
the pain, and redness. In sclerotitis the vessels are deep-seated, of 
a pale pink colour, and run in straight lines from the circumference 
of the eye towards the cornea; whereas in conjunctivitis^ the vessels 
are tortuous, freely anastomose, superficial, and are of a bright-red 
colour. 

Treatment. — Bleeding, purging, together with the administration 
of colchicum, warm baths, and anodyne fomentations ) blisters be- 
hind the ears, and Dover's powder, are also of great avail. 

IRITIS. 

This often is caused by injury or cold, but oftener by scrofulous, 
syphilitic, or gouty taint. 

Si/mjHorns. — The iris changes in colour; appears rough or vil- 
lous; the pupil is contracted, and often filled with lymph; a pink 
zone surrounds the cornea, formed by small vessels from the sclero- 
tica; there is intolerance of light, dimness of vision, a burning pain 
in the eye, and an aching pain over the brow. 

Treatment. — The inflammation should be subdued bv active an- 



126 SURGERY. 

tiplilogistic means, sucli as bleeding, purging, and leeching. The 
absorption of lymph is to be promoted, and its fresh effusion ar- 
rested by the administration of small doses of calomel and opium 
every four hours, until the gums become affected. The pupil should 
be kept well dilated by belladonna or stramonium, and the pain 
must be relieved by anodyne fomentations and nightly doses of opium. 
Artificial Pupil. — It is often necessary to form a new aperture in 
the iris, owing to the pupil having been obliterated by inflammation. 

C A T A RAC T 

Is an opacity of the lens or its capsules. It may be caused by in- 
flammation or injury, but is more frequently the result of impaired 
nutrition. There are different varieties of cataract, designated by 
the terms hard, soft, radiated, capsular, &c. 

Symptoms. — The vision becomes gradually impaired, and objects 
appear as if surrounded by a mist or cloud. The sight is better in the 
evening, or after the application of belladonna, because the pupil 
being dilated, more light passes through that part of the lens which 
may yet be transparent. The pupil is active, and behind it is an 
opaque body of a grayish-white or amber colour. The catoptric test 
is the most certain mode of distinguishing it from amaurosis and 
glaucoma. When a lighted candle is held before the healthy or 
amaurotic eye, three images of it may be seen : an erect image, that 
moves upwards when the candle is moved upwards, which is pro- 
duced by reflection from the surface of the cornea ; another erect 
image, produced by reflection from the anterior surface of the lens, 
which also moves upwards when the candle moves upwards ; and a 
very small inverted image, that is reflected from the posterior sur- 
face of the crystalline, that moves downwards when the candle is 
moved upwards. In cataract, this inverted image is from the first 
rendered indistinct, and soon abolished; and the deep erect one is 
soon abolished also. 

Treatment. — There is no cure but by an operation, which should 
be deferred until the patient is in good health and condition. If 
the iris moves freely, and there is no tendency to vascular disturb- 
ance in the eye or head, the chances are favourable. — There are 
three modes of operating, before performing either of which the 
pupil should be dilated by belladonna or stramonium. 

Extraction. — An incision is made through one half of the circum- 
ference of the cornea, the capsule of the lens lacerated, and the 
cataract extracted entire. 

Couching or Depression. — The object of this operation is to re- 
move the cataract from the axis of the vision, and is performed by 
a couching needle passed through the outer side of the sclerotica, 
about two lines from the margin of the cornea. 

Producing Absorption. — The needle is introduced in the same 



AMAUROSIS. 127 

manner as in depression^ the lens broken up and subjected to the 
absorbent influence of the aqueous humour. 

AMAUROSIS 

Is an imperfection of vision^ arising from some change in the 
retina^ optic nerve, brain, or fifth pair of nerves. 

Symjytoms. — The sight is impaired by degrees ; at times vision is 
more impaired that at others ; objects appear double, crooked, or 
discoloured ; black spots or flashes of light, a vacant stare, dilated 
pupil, and but little motion of the eyelids, indicate amaurosis. There 
is often a want of the natural colour of the pupil, which may cause 
it to be mistaken for cataract, from which it is most certain to be 
distinguished by the catoptric test, as well as by rational signs. The 
usual causes are circumstances which over-stimulate the retina, such 
as glaring lights, heats, intemperance, tight neck-cloths; also in- 
flammation, concussion, extravasations, tumours, &c. 

Treatment. — Should it be inflammatory, produced by wounds, 
lightning, or exposure to intense light ; or if there are plethora, head- 
ache, giddiness, turgid countenance, and frequent flashes of light 
when stooping ; or if the complaint has followed a suppression of 
any accustomed evacuation, or the drying up of an habitual ulcer or 
eruption, then the antiphlogistic treatment must be adopted, — bleed- 
ing, cupping, counter-irritants, and purgatives. Should it be atonic, 
the result of a protracted illness, great loss of blood, over-lactation, 
leucorrhoea, or other debilitating circumstances, it is attended with 
pallid lips, dilated pupils, trembling pulse, and despondency of mind. 
The patient usually sees best after eating, and in a strong light. The 
discharge or other source of exhaustion should be corrected, and the 
system strengthened by fresh air, tonics, quinine, steel, good living, 
&c. The secretions should be well regulated, and the cutaneous 
and general circulation be promoted by exercise and bathing. 

Should it be sympathetic, supervening on jaundice, some disorder 
of the stomach, or worms, the general health must be regulated be- 
fore a cure can be expected. It may arise from tumours near the 
eye and carious teeth, which should be removed. If it follow an 
injury of the fifth pair of nerves, the wound should be dilated ; or 
if it be healed, the cicatrice must be cut out. Should it follow the 
use of tobacco or opium, it may be relieved by a cold shower-bath, 
counter-irritation, and electricity. Should it be organic, the treat- 
ment should be palliative. 

STRABISMUS. 

Stralmmus or Sijuinting is the want of harmonious action of the 
muscles of the eyeball. It may be caused by the overaction or the 
paralysis of a muscle. The ordinary varieties are the convergent, 
looking inwards, and the divergent, looking outwards : the former 
is the more frequent. It may be congenital, but usually occurs in 



128 



SURGERY. 



Fig. 50. 




childhood. Sometimes it is the result of imita- 
tion • or it may be induced by marks or patches 
on the nose; but oftener it is occasioned by 
gastric or intestinal irritation. Cerebral disturb- 
ance is another cause, especially when the squint 
does not come until adult age. 

Treatment. — In childhood, where squinting de- 
pends on sympathetic disturbance, it is often re- 
moved by purgatives, alteratives, or anthelmintics. 

Some cases of squinting may be cured by di- 
vision of a muscle, but not all ; in fact, a deformity 
sometimes results from the operation. 

In almost all cases of squinting, there is defec- 
tive vision in the affected eye ; this defect is usually 
relieved when the operation is properly performed. 
The patient should be steadied, as for other oph- 
thalmic operations. The eyelids are to be sepa- 
rated by an assistant or speculum, and the eye not 
to be operated on is carefully to be bandaged. 

The conjunctiva is to be seized by a small 
toothed forceps, about midway between the cornea 
and the caruiicle, so as to form a horizontal fold, 
which is to be snipped by the scissors close to the 
forceps, and between them and the cornea ; or, 
this fold of conjunctiva may be divided by an iris 
knife. After the division, the conjunctiva is to be 
separated from the sclerotica for a slight distance. 
The third step consists in the introduction of a 
blunt hook, which is curved so as to accommodate 
itself exactly to the curvature of the eyeball. The 
hook is to be passed under the tendon, from above 
downwards ; and the muscle now being secure, it 
is to be divided by a pair of scissors. If the pupil 
is now in the centre of the orbit, and if the patient 
cannot turn the eye horizontally inwards, the ope- 
ration may be considered as complete. Should a 
portion of the muscle, or some tendinous fibres 
remain undivided, they are to be sought for by the 
blunt hook, and divided. If the fascia is too ex- 
tensively divided, the eye will become too promi- 
nent, or an external squint will result. 

After the operation cold water is all that need 
be applied. The operated eye should be exclu- 
sively used for a few days. A fungous granulation 
often rises from the wound, which may be removed 
by the knife, scissors, or lunar caustic. 



GLOSSARY. 



Achromatopsia (a, priv. xp^p^a, colour, ojip, the eye), want of power to distin- 
guish colours. 

Aegilops {alyiXuxp, from ai^, alydg, a goat, ojip, the eye), a name given by the 
older surgeons to a sinuous ulcer at the inner corner of the eye, from its resem- 
blance to the larmier, or infra-orbital glandular sac of goats and other ruminating 
animals. 

Albugo (albus, white), an opacity of the cornea. 

Amaurosis {dixavpaxng, obscuration, from d[A.avp6u>, to render obscure), impairment 
or loss of vision from paralysis of the optic nervous apparatus. 

Amblyopia {dixpXvg, dull, ojip,tke eye), impaired vision from defective sensibility 
of the retina. 

Amphiblestroiditis {dn(pi0\r]aTpo£i6hs, the retina, from djjKpiPXrjarpov, a 7iet, and 
£76os,form), retinitis, or inflammation of the retina. 

Anchilops {dyxi^(o4^, from «yXS^^^^% ai'^d wi//, the eye), name given by the older 
surgeons to the abscess at the inner corner of the eye, ending in the sinuous 
ulcer which they called Aegilops. 

Anchyloblepharon {dyKvXog, crooked, (^\k(f)apov, eyelid), cohesion of the eyelids to 
each other at their borders. 

Asthenopy (a, priv., aBhog, strength, and wi//, the eye), weaksightedness. 

Atresia (a, priv., nrpdoi, to perforate), closure or imperforation ; applied to the 
pupil, &c. 

Blepharitis {(^Xtcpapov, eyelid), inflammation of the eyelids. 

Blepharoblennorrhoea 0\e(papov, eyelid, j3\si/va, mucus, pscxi, to flow), first stage 
of puro-mucous inflammation of the conjunctiva. 

B I ephar ophthalmia {pXecpapov, eyelid, 6(pBa\ixdg, eye), called also Blepharoph- 
thalmo-blennorrhoea, puro-mucous inflammation of the conjunctiva in its fully- 
formed state. 

Blepharoplegia {(3\erf)apov, eyelid, TrXjyyj), stroke or bloio), paralysis of the eyelid. 

Blepharoptosis {(3\s(papov, eyelid, Trrcoais, d falling down), called also simply 
Ptosis, a falling down of the upper eyelid. 

Blepharospasmus {p\e(papov, eyelid, arraaixog, spasm), spasm of the eyelids. 

Buphthalmos {^ovg, ox, 6(p0a\nog, eye), Oculus Bovinus, dropsical enlargement 
of the eye. 

Canthus {Kavdog, the rim of a wheel), angle of the eye. 

Cataract {KaTapdKvrjg, from Karappdaao), to throw dow?i with violeiice, to break or 
disturb), opacity of the lens or its capsule. 

Ceratitis {Kcpag, horn, cornea), inflammation of the cornea. 

Ceratocele {Kepag, horn, cornea, KriXr], tinnour), hernia of the cornea. 

Ceratome (Kspag, cornea, TopLy), section),^ knife for making an incision of the 
cornea. 

Chalazion (xdXa^a, grando, or hailstone), a small tumour of the eyelid. 

Chemosis {x^p-cotng, irom X'V??, a gaping, from x^no, to gape; or \vLUx}<Tig, from 
%v/xof, humour, or fluid), elevation of the conjunctiva like a wall round the cornea, 
from exudation into the subjacent cellular tissue. 

Choroiditis (choroid, from x^piov, chorion, one of the menibranes of the foetus, 
ftJoj, ZiA^e;iess), inflammation of the choroid. 



130 SURGERY. 

Chromatopsy, or Chromopsy (xpf^i^a, colour, oiptg, vision), chromatic or coloured 
vision. 

Chroopsy, or Chrupsy ixp<joLj colour, oip is, vision), chromatic vision. 

Cilia (celo, to cover or conceal, because they cover and protect the eye, or from 
cieo, to move), eyelashes. 

Cirs ophthalmia {Kipaog, varix, d(p6a\iJLdg, the eye), a varicose state of the blood- 
vessels of the eye. 

Clavus {the head of a nail), a certain degree of prolapse of the iris, through an 
opening in the cornea; the prolapsed portion of the iris being pressed flat like 
the head of a nail. 

Colly rium {KoWvpiov, from KoWvpa, a cake; bread sopped according to Scaliger, 
this being a common application to the eyes), a medicine for the eyes. 

Colohoma {KoXdpojxa, mutilation), applied to fissures of the eyelids and of the 
iris, congenital or traumatic. 

Corectomia {Kopn, pupil, ek, out, rEjxvoi, to cut), operation for artificial pupil by 
excision. 

Coredialysis {Kopr], pupil, StaXvoj, to loosen), operation for artificial pupil by 
separation. 

Coremorphosis {Koprj, pupil, ii6p(poiaig , formation) , operation for artificial pupil in 
general. 

Coreoncion {Kopr}, pupil, oyKog, hook), hook invented for the operation for arti- 
ficial pupil by separation. 

Coreplastice {Koprj, pupil, nXaariKri, the art of making images), operation for arti- 
ficial pupil in general. 

Cornea [cornu, horn), the cornea is so called from its horny appearance. 

Corotomia {Kopn, pupil, repLvoy, to cut), operation for artificial pupil by incision. 

Curette {French for a small spoon), DavieV s spoon, an instrument used to assist 
the exit of the lens in the operation of extraction. 

Dacryoadenitis {daKpvoj, to weep, aSiiv, gland), inflammation of the lachrymal 
gland. 

Dacryocystitis {SaKpvo), to weep, Kva-Lg, sac), inflammation of the lachrymal 
sac. 

Dacryo-cysto-blennorrhcea {SaKpvco. to weep, Kvang, sac, pXsuva, mucus, peco, to 
flow), blennorrhoea of the lachrymal sac. 

Dacryohcemorrhysis {daKpvoj, to weep, a'lpa, blood, pea), to flow), sanguineous 
lachrymation. 

Dacryolites {SaKpvco, to weep, \idog, a stone), calculous concretions deposited in 
the lachrymal passages. 

Dacryoma {oaKpvoy, to weep), stillicidium lachrymarum. 

Diplopy {6i~\6og, double, o^-'dj, vision), double vision. 

Distichiasis {olg, twice, crixog, a row), a form of trichiasis in which the mal- 
directed eyelashes form a second row, distinct from the others. 

Ectropium CEKvpomov, from ck, out, Tpsnw, to turn), eversion of the eyelids. 

Encanthis {ev, in, KavBog, the corner of the eye), enlargement of the lachrymal 
caruncle. 

Eiitropium {h, i7i, rpcrrw, to turn), inversion of the eyelids. 

Epicanthus (m, upon, KavQog, angle of the eye), a congenital peculiarity of a 
fold of skin extending over the inner canthus. 

Epiphora {em, upon, (pepo), to carry), watery eye from excess of lachrymal se- 
cretion. 

Exophthalmos and Exophthalmia {i^, out, 6(p0a\ndg, eye), protrusion of the 
eyeball. Exophthalmos is used when the eyeball is otherwise uninjured ; 
exophthalmia, when, in addition to the protrusion, there is disorganization of the 
eyeball. 

Geronioxon {ytpoiv, old, ro^ov, a bow), arcus senilis. 

Glaucoma {yXavKog, sea-green), a greenish opaque appearance behind the 
pupil. 

Grando {hailstone), a small tumour of the eyelid. 

Gutta opaca, name given by the Arabians to cataract, as they supposed it an 
opaque drop in front of the lens. 



GLOSSARY. 131 

Gutta sere7ia (drop serene), name given by the Arabians to amaurosis, sup- 
posing it to depend on a clear drop fallen from the brain into the eye. 

HcBinophthalmos , Hcemophthalmia (aqxa, blood, d-jjOoKjicig, the eye), sanguineous 
effusion into the eye. 

Hemeralopia O'luspa, day, oif^ts, vision), night-blindness. It has been also em- 
ployed to mean day-blindness {riix':pa,day, a priv., or aXadg, hlind, oijjig, vision). 

Hemiopy OyKcrvg, half, oipig, vision), a defective state of vision, in which one 
half of objects only is seen. 

Hordeolum (hordeum, barley), stye. 

Hyalitis, or Hyaloiditis {vaXo;, glass), inflammation of the hyaloid mem- 
brane. 

Hydr ophthalmia, or Hydrophthalmos {vdojp, vjater, drjjOa'Xjj/js, the eye), dropsy of 
the eye. 

Hyperkeratosis {vnep, above, Kspag, cornea), conical cornea. 

HypocBma {vnd, under, aijia, blood), blood in the anterior chamber. 

Hypochyma {vKoxvi^a, or vn-oxvaig, from vn-d, u7ider, :\:u/^a, effusion), cataract. 

Hypogala {vnd, under, ydXa, milk), effusion of a milky-like matter in the anterior 
chamber. 

Hypopyon {vno, uoider, ttvov, pus), pus in the anterior chamber. 

Iriankistron {Xpig, iris, ciyKtarpoi^, a jisli-hook), an instrument invented for per- 
forming the operation of artificial pupil by separation. 

Iridauxesis (ipig, iris, av^/jcrig, grovHh), thickening or growth of the iris from 
exudation into its substance. 

Iridoncosis Clpts, iris, and oyKog, tumour), a name formerly proposed by Von 
Ammon for the same morbid state of the iris, as that to Vv^hich he has since given 
the name Iridauxesis ; but now applied to an abscess of the iris. 

Iridectomia {Iptg, iris, IV, out, tsjavoj, to cut), operation for artificial pupil by ex- 
cision. 

Iridectomedialysis C^pig, iris, bk, out, rtfxvo, to cut, Sid^vaig, s eparatio?t), oper3.tion 
for artificial pupil by a combination of excision and separation. 

Iridencleisis (Ipig, iris, ev, in, and /cAsiw, to close), the strangulation of a pro- 
lapsed, portion of the iris between the lips of an incision in the cornea in certain 
operations for artificial pupil. 

Iridodialysis Cipig, iris, SidXvaig, separation), the operation for artificial pupil by 
separation. 

Iridoschisma (i'pij, iris, ^(xx^iG-fxa, fissure), a fissure of the iris. See Coloboma 
iridis. 

Iridoiomia (Fptj, iris, TOfxr], section), the operation for artificial pupil by in- 
cision. 

Iridoperiphakitis (Ipig, iris, Trepl, over, (pcKog, a lens or Ze;i^iZ), inflammation of the 
uvea and anterior wall of capsule of the lens. 

Keratitis (Kcpag, horn, cornea), inflammation of the cornea. 

Keratonyxis {Kspag, cornea, vvfig, a puncture), corneal puncturation in needle 
operations for cataract. 

Korectomia. See Corectomia. 

Koredialysis. See Coredialysis. 

Koromorphosis. See Coromorphosis. 

Koreplastice. See Coreplastice. 

Korotomia. See Corotomia. 

Lagophthalmos (Kayog, a hare, 6^j)da\ixdg, the eye), oculus leporinus, or hare's 
eye. Retraction or shortening of either eyelid. 

Leucoma (Xcokooj, to iDhiten, or \cvK6g, ichite), opacity of the cornea from a cica- 
trice. 

Lippitudo (lippus, blear-eyed), blear eye. 

Luscitas (luscus, blind of one eye), fixed misdirection of the eye. 

Madarosis (ixaSapcoaig, from [xaSdg, bald), a falling out of the eyelashes. 

Marmaryge, {[xapixapvyi), splendour), an appearance of sparks or coruscations 
before the eyes. 

Metamurphopsy (ncranopcpdco, to transform, oipig, visio7i), distorted appearance of 
objects. 



132 SURGERY. 

Mkrophthalmos ([iiKpSg, small, dpOaXixos, the eye), smallness of the eye from im- 
perfect development. 

Mkropy {[JLiKpoS, small, oipig, vision), a state of vision in which objects appear 
smaller than natural. 

Milium (a millet seed), a small white tumour of the eyelids or their neighbour- 
hood. 

Monohlepsis (ixSvog, single, l3\eipis, view), state in which vision is distinct only 
when one eye is used. 

Mucocele ijxv^a, mucus, KfiXi), a tumour), dropsy of the lachrymal sac. 

MusccB volitantes (musca, afiy, volito, to jiy about), the appearance of grayish 
motes before the eyes. 

Mydriasis {aixvSpdg, obscure, or jxvSdo), to abound in moisture, because it was 
supposed to be owing to redundant moisture), preternatural dilatation of the 
pupil. 

Myocephalon (^vta, a fly, KS(pa\^i, the head), a small protrusion of the iris, like a 
fly's head, through an ulcerated opening in the cornea. 

Myodesopsia {jivia, a fly, dipcs, visio7i), muscae volitantes. 

Myopy (nvo), to shut, osip, the eye), nearsightedness. 

Myosis iixvoi, to shut), preternatural contraction of the pupil. 

Myotomy {^ivs, a muscle, reixvo), to cut), section of muscles. Ocular myotomy, 
section of muscles in strabismus. 

Nyctalopia (vv^, night, oipig, vision), day-blindness. Employed also for night- 
blindness {vv^, a priv., or aXaog, blind, o^ig, vision). 

Nystagmus {waTayiJidg, steep), oscillation of the eyeball. 

Oculus Bovinus (bos, bovis, a?i ox), ox-eye ; see Buphthalmos. 

Oculus Le'porinus (lepus, leporis, a hare), hare's eye; see Lagophthalmos. 

Onyx (owl, ^ nail), deposition of matter in the substance of the cornea. 

Ophthalmia id(pda\ixds, the eye), a general name for inflammation of the eye. 

Ophthalmia Neonatorum {vtog, young), purulent ophthalmia of new-born in- 
fants. 

Ophthalmitis, inflammation of the whole eyeball. 

Ophthalmodynia, {6:pOa'X[xds, eye, d6vvTi,pain), pain in the eye. 

Ophthalmology {d(pda\ndg, eye, \6yog, a discourse), the science of ophthalmic 
medicine and surgery. 

Ophthalmoplegia {o(pda\}xdg, eye, 7rXvy>>, a blow or stroJce), paralysis of the mus- 
cles of the eyeball. 

Ophthalmoptosis i6(p9a\ixdg, eye, nrojaig, a falling down, from -itttoj, to fall), the 
protrusion or the eyeball, resulting from paralysis of its muscles. 

Oxyopia {o^vg, sharp, okb, the eye), preternatural acuteness of vision. 

Facheablephara, Fachytes {rraxvriig, thickness, from naxvg, thick, pXecpapov, eyelid)^ 
enlargement and thickening ot the eyelid. 

FalpebrcB (a palpitando,/ro77i their frequent motion), the eyelids. 

Fannus (pannus, cloth), a thickened and vascular state of the conjunctiva 
corneas. 

Feriorbita {TVEpl, over), the periosteum of the orbit. 

Fhlyctenula {(pXvKraiva, a vesicle, from (pXv^o), to gush forth), vesicle filled with 
a watery fluid. 

Fhotophobia {(pcog, light, <po(^eoi, to dread), intolerance of light. 

Fhotopsia C^cDj, light, oibig, vision), subjective appearance of light before the 
eyes. 

Fhtheiriasis {(pOeipiacng, morbus pedicularis, from 00ap, a louse), pediculi among 
the eyelashes and hairs of the eyebrows. 

Pinguecula (pinguis,/ai), a small tumour on the white of the eye near the 
edge of the cornea, apparently but not really adipose. 

Fladarotes {irXaSapog, flaccid), thickening of the palpebral conjunctiva. 

Fresbyopy {Trptapvg, old, coip, the eye), farsightedness. 

Froptosis (npo, before, nrojaig, a falling down, from -nrroi, to fall); see Ophthal- 
moptosis. 

Fsor ophthalmia (i//wpa scabies, d(p6a\ixdg, the eye), ophthalmia tarsi. 

Pterygium {jrrepdv^ a wing, itrepvyiov, a small wing), thickened and vascular state 



GLOSSARY. 133 

of a portion of the conjunctiva, of a triangular shape, the apex encroaching more 
or less on the cornea. 

Plilosis {irriXoiGis, Laid), falling out of the clUa ; see Madarosis. 

Ptosis {iTTcoais, a falling down, from Trnrro}, to fall), falling down of the upper 
eyelid. 

Pupil (pupilla), the aperture in the iris. 

Retinitis (rete, a net), inflammation of the retina. 

Rliexis, or Rhegma Oculi (pn^ig and phyi^a, a rupture), rupture of the eyeball. 

Rhytidosis (pvriScjaig, a wrinkliiig, from pvnooo), to wrinkle), collapsed or con- 
tracted state of the cornea. 

Sclerotitis {aKXrjpds, 7iar^), inflammation of the sclerotica. 

Scotomata (o-zcdrco/xa, dizziness, from orKordoj, to darken), dark spots seen before 
the eyes; see Muscce Volitantes. 

Staphyloma {ara(pv\ri, a grape), a projection of some part of the eyeball, gene- 
rally of the cornea and the iris, or sclerotica and choroid. 

Staphyloma Racemosum (racemus, a hunch of grapes), staphyloma is so called 
when there is an appearance of several projections. 

Stenochoria {arevoxwpia, narrow7iess of space, from (rrevog, narrow, x^^jpog, space), 
a contraction, applied to the derivative lachrymal passages. 

Stillicidium (stillo, to drop, cado, to fall), dropping of tears from the eye, in 
consequence of obstruction of the derivative lachrymal passages. 

Strabismus iarpaPi^o), to squint, from crpaPog, twisted), squinting. 

Symblepharon {avv, together, p\t(papov, eyelid), adhesion of the eyelids to the 
eyeball. 

Synchesis {avyxv(ns, mixture, from a-vv, together, and x^(^i to pour), dissolution 
of the vitreous body. 

Synechia {avvex^ia, co7iti?iuity , from awixoi), to keep together), adhesion of the iris 
to the cornea or capsule of the lens; in the former case it is distinguished as an- 
terior synechia, in the latter as posterior synechia. 

Synizesis {avvt^rjais, a falling together, from crvvi^eo), to set together), closure of 
the pupil. 

Tarsoraphia (rapaog, tarsus, pacpf], a suture), suture of the tarsal margins in 
ectropium of the external angle. 

Taraxis {rdpa^ig, disturbance, from rapdaaoi, to disturb), slight external oph- 
thalmia. 

Trachoma {rpaxofxa, roughness, TpaxSoj, to make rough), granular conjunctiva. 

Trichiasis {dpi^, a hair), inversion of the eyelashes. 

Trichosis {Bpil^ a hair), Trichosis Bulbi, a small tumour on the front of the eye- 
ball, with hair growing from it. 

Tylosis (rvXog, callosity), thickening and induration of the borders of the 
eyelids. 

Xeroma, Xerophthalmia, Xerosis {'^ripijg, dry), dryness of the eye, of which there 
are two kinds, viz., conjunctival and lachrymal. 



THE END. 






LIBRARY OF CONGRESS |^] 

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